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THE DISEASES OF THE EAR 



PRACTICAL TREATISE 



ON THE 



DISEASES OF THE EAR 



INCLUDING 



A SKETCH OF AURAL ANATOMY AND 
PHYSIOLOGY 



R B. ST. JOHN EOOSA, M.D., LL.D. 

Professor of Diseases of the Eye and Ear in the Neic York Post- Graduate Medical School 
and President of the Faculty ; Surgeon to the Manhattan Eye and Ear Hospital; 
Consulting Surgeon to the Brooklyn Eye and Ear Hospital; formerly Pro- 
fessor of Ophthalmology in tlie University of the City of New York, 
and of Diseases of tlie Eye and Ear in tJie University of Ver- 
mont ; formerly President of tlie Medical Society 
of the State of New York, etc. , etc. 



I I 






SIXTH EDITION 
REVISED AND ENLARG 



NEW YORK 

WILLIAM WOOD & COMPANY 

50 and 58 Lafayette Place 

1885 








^ 



<\ 



Copyright, 18S5, 
3y WILLIAM WOOD & CO. 



TROWS 

PRINTING AND BOOKBINDING COMPANY. 

NEW vQRK. 



I- 

i 



TO MY FRIEND 

Efcwarfc XTalbot JElv, flh.W. 

IN REMEMBRANCE OF OUR YEARS OF INTIMATE PROFESSIONAL AND SOCIAL 

RELATIONS, THIS BOOK IS AFFECTIONATELY 

DEDICATED 



PREFACE TO THE SIXTH EDITION, 



It is now eleven years since the first edition of this work was 
published. The manner in which it has been received by the 
profession of this country and of Great Britain and Ireland, has 
been a source of great gratification to me. I offer my hearty 
thanks to my brethren for having given my labors in otology 
such a kind appreciation. In revising this book, while perhaps 
no page has escaped alteration, and many pages have been 
added, pains have been taken to preserve the original plan. 
It was written for three classes of readers. First, it is intended 
to be a means by which advanced medical students may acquire 
a knowledge of the diseases and anatomy of the ear. Second, it 
is designed for general practitioners, to whom it may be a guide 
for the diagnosis and treatment of cases actually in hand. Third, 
I also hope, that professional men who interest themselves 
largely or exclusively in otology, may in the future as in the 
past, find in it something of interest and profit to them. 

The larger part of the work is essentially a digest of my own 
experience in the treatment of diseases of the ear, now ex- 
tending over more than twelve thousand cases for which I have 
had the personal responsibility. The nomenclature of this 
book has been accepted quite generally in the profession, and 
some of the views which were set forth for the first time in the 
first edition, have been recognized as true, and have taken their 
place in the great structure of human knowledge. 

In this edition, it will be found that I have endeavored to 



Vlll PREFACE TO THE SIXTH EDITION. 

make deductions from my clinical experience in certain novel 
directions. Time will eventually establish the truth, or expose 
the incorrectness of the conclusions which I have drawn from 
my cases. If any of them are wrong, the facts at least will re- 
main, I trust, a substantial contribution to a department of 
medicine to which I have given some of the best years of my life. 

I wish to express my thanks to my valued friend, Dr. 
Charles E. Hackley, for his aid and advice in correcting the 
proofs, also to Dr. J. B. Emerson for the preparation of the in- 
dex, and much other assistance. 

Man}^ of the anatomical illustrations were prepared expressly 
for this edition, and most of these are from the museum of my 
distinguished colleague, Professor William Darling. While en- 
gaged upon this work, Dr. John L. Yandervoort has extended 
to me great courtesy in his official position as Librarian of the 
Xew York Hospital. Many of the engravings of instruments 
were furnished me by Messrs. John Reynders & Co. 

New York, November 1, 1884. 



PREFACE TO THE FIRST EDITION. 



This work is intended to be a guide to those who wish to treat 
the diseases of the ear. The portion that is devoted to a de- 
scription of these diseases, and the means for their relief and 
cure, is founded upon my own experience in the observation and 
treatment of more than thirty-eight hundred cases, in public 
and private practice. I have, however, taken pains to give the ex- 
perience of other practitioners, both at home and abroad. I have 
endeavored not only to give a comprehensive digest of the most 
recent European researches, but also to present, with entire im- 
partiality, the views and experiences of American practitioners 
and writers, so far as the plan of a practical treatise like this 
would allow. To give a complete account of all that has been 
written on otology has not, however, been my aim. 

Considerable space has been given to illustrative cases, with a 
view of showing the actual symptoms of aural diseases and the 
results of treatment. I have also added historical sketches upon 
all points of practice that are new or still under discussion, in 
order that the successive steps by which our present position has 
been reached might be distinctly traced, believing that thereby 
the practitioner will often be saved needless labor in re-investi- 
gating and re-experimenting. The nomenclature contained in 
this treatise is that which I have found, after some j^ears of ex- 
perience in lecturing upon diseases of the ear, most readily 
grasped by the student, and is, I believe, founded upon the 
real nature of the diseases. 

The anatomical portion of the volume has been compiled from 
the most recent authorities. The text-book of Professor ,1. 
Henle, of Gottingen, a work which has not been translated into 



X PREFACE TO THE FIRST EDITION. 

English, has been made the general basis of the descriptions of the 
various parts of the ear, and of the arrangement of the subject. 

In the preface to a translation of "Yon Troltsch on the Ear," 
published a little more than nine years since, the translator had 
so little faith in a general professional interest in the diagnosis 
and treatment of diseases of the ear, that he quoted a proverb 
to indicate that an ordinary human life would not suffice to see 
the fruit of the tree then being planted, in presenting to the 
English-speaking profession a work which has done much for 
the progress of otology. 1 „ 

In view, however, of the active and permanent interest in this 
subject, which has shown itself in the formation of societies, the 
establishment of journals, improvements in methods of practice, 
and a general appreciation of diseases of the ear, the author can 
but felicitate himself that even in a short life .he has seen some 
fruit of a tree, which, although he did not plant, he at least as- 
sisted in cultivating. 

The practice of otology in this country was, a few years 
since, almost exclusively confined to charlatans ; but it is now 
cultivated by a class of men who are the equals of any in the 
profession. Ten years ago, in most parts of the country, those 
who wished advice upon a disease of the ear were forced to seek 
aid outside of the profession. At the present time, there can 
be found those in the large cities who are constantly and suc- 
cessfully treating aural diseases ; and all over the land the old 
and familiar advice, " Not to meddle with the ear," is growing 
far less frequent. The day will soon arrive — if indeed it be not 
already upon us — when otology will take equal rank with 
ophthalmology, to which department it has so long been a 
mere appendage, and when some knowledge of the diseases and 
treatment of the ear will be required of every practitioner. 

I have been assisted in various ways, in the preparation of 
this work, by many who may rest assured that I have not been 
unmindful of their labors because their names are not here 
mentioned ; but to Dr. Charles E. Rider, of Rochester, for assist- 
ance in compiling the anatomy of the middle ear, and to Dr. 
George M. Beard, for critical suggestions in the literary execu- 
tion of the work, of a very valuable character, I am much in- 



" Arbores seret diligens agricola quarum adspiciet baccara ipse nimquam." 



PREFACE TO THE FIRST EDITION. XI 

debted, and to both of these gentlemen I desire to present my 
cordial acknowledgments. 

It is believed that in the foot-notes, the various authorities 
whom I have consulted Lave been given proper credit, and they 
are given in full at the close of the sketch of the progress of 
otology, and at the end of each anatomical section, in order 
that an aural bibliography of works actually consulted by the 
author, and accessible in this country, may be furnished to 
any who ma}^ desire to pursue any special subjects further than 
would be fitting the limits of a text-book. 

Most of the engravings were made by Messrs. J. A. Cough- 
Ian & Co. Those of instruments were furnished by Messrs. 
Shepard & Dudley, Otto & Reynders, and George Tiemann & 
Co., of this city. 

The chromo-lithographs were drawn by Dr. H. P. Quincy, 
of Boston, from cases loaned me by Drs. Clarence J. Blake and 
Henry L. Shaw, Surgeons to the Massachusetts Charitable Eye 
and Ear Infirmary. Without the assistance of these gentlemen, 
I should have found it very difficult to procure satisfactory 
representations of the morbid membrana tympani. Dr. John 
L. Yandervoort, Librarian of the New York Hospital, has ex- 
tended me many courtesies in giving me free access to the 
valuable library of that institution. 

New Yoek, May 29, 1873. 



CONTENTS 



CHAPTER I. 



A SKETCH OF THE PEOGEESS OF OTOLOGY WITH A BIBLI- 

OGEAPHY. 

PAGE 

Vastness of Otological Literature. — Apathy in regard to Diseases of the Ear. — Wilde 
the Reformer of the Science. — Carl Gustav Lincke and his Handbook. — Papy- 
rus Ebers. — Hippocrates and his Knowledge of the Ear. — Alcmseou the Dis- 
coverer of the Eustachian Tube. — Rufus of Ephesus. — Aristotle. — Discoveries 
in the Time of the Ptolemys. — Galen and the Want of Progress in his Time. 
— Achillini and Berengario describe the Ossicles. — Vesalius the most accurate 
Anatomist of his Day. — Ingrassia, Columbo, and Eustachius each claims Dis- 
covery of Stapes. — Fallopius and his Career. — Anatomical Writings of Eusta- 
chius. — First Monograph on Anatomy of the Ear. — Constant Varolius. — Fab- 
ricius of Aquapendente. — Valsalva. — Casserius, a Pupil and Rival of Fabricius. 
— Stenon describes Ceruminous Glands. — Discovery of Helicotrema. — Du Ver- 
ney and his Plates. — Cotugno and the Aqueducts. — Meckel. — Rivinian Fora- 
men. — Hyrtl and Bochdalek upon its Existence. — Ruysch. — Brendel and 
Zinn. — Scarpa upon the Internal Ear. — Saunders, Todd, and others. — Monro's 
Claim to have first traced the Nerves into the Cochlea, Vestibule, and Semi- 
circular Canals. — Everard Home's Account of the Membrana Tympani. — 
Soemmering. — Shrapnell. — Thomas Buchanan on the Importance of Cerumen. 
— Wharton Jones. — Discoveries of Toynbee. — Troltsch, Politzer, Lucre, and 
others. — The Organ of Corti and its Discoverer. — Pathological Anatomy of the 
Ear. — Progress in Treatment of Aural Disease. — Herodotus on Specialists. — 
The Remedies suggested by Hippocrates. — Celsus. — Archigenes on Venesection 
and Foreign Bodies. — Galen on Noise. — Peculiar Method of removing Foreign 
Body from Ear. — Paulus iEgineta, his Classification and Operation. — Arabians, 
their Knowledge of Otology. — Paracelsus burning Books of his Predecessors. — 
Capivacci on Differential Diagnosis. — Ambroise Pare first uses a Syringe for 
the Ear.— The Education of Deaf Mutes.— Old Method of detecting Inspis- 
sated Cerumen. — Lusitanus on cutting off Ears of Thieves. — Fabricius of Hil- 
den. — Thomas Willis, his Observations on Hearing in a Noise. — The Thera- 
peutical Work of Valsalva. — Petit on Caries of the Mastoid. — The Discovery 
of the Eustachian Catheter. — Guyot, Cleland. — Perforation of the Membrana 
Tympani. — Trephining the Mastoid. — Sir Astley Cooper. — Saunders on Perfo- 
ration of the Membrana Tympani. — First Infirmary tor Diseases of the Ear. — 
Saissy, Itard, Beck. — Sketch of Kramer's Career. — Discovery of Artificial 
Membrana Tympani.— Yearsley. — Wilde and his great Work in Otology. — 
The Text-books of Toynbee, Troltsch, Erbard. — Modern Text-books and Jour- 
nals. — Bibliography, 1 



XIV CONTENTS. 

CHAPTER II. 
THE EXAMINATION OF AUKAL PATIENTS. 

PAGE 

History. — Power of Hearing Conversation. — Test Sentences. — Tick of a Watch. — 
Tuning-fork. — -Aerial and Bone Conduction. — Malingering. — Angular Forceps. 
— Specula. — Troltsch's Otoscope. — Examination of Pharynx. — Rhinoscopy. — 
Use of Eustachian Catheter. — Politzer's Method and its so-called Modifica- 
tions. — Bougies. — Valsalva's Method, 44 



CHAPTER III. 

anatomy; and physiology of the auricle and the 
external auditory canal. 

Auricle. — Etymology. — Anatomy of Muscles, Intrinsic and External. — Physiology. 
— Blood-vessels. — Nerves. — External Auditory Canal. — Anatomy of Curva- 
ture. — Ceruminous Glands. — Hairs in Canal. — Auditory Canal of Dog and Cat. 
— Relations of Canal to Parotid Gland, Inferior Maxilla, Mastoid Process, and 
Dura Mater. — Blood-vessels and Nerves, .81 



CHAPTER IV. 
THE MALFORMATIONS AND DISEASES OF THE AURICLE. 

A Finely Formed Auricle an Indication of Character. — Malformations. — Super- 
fluous Auricles. — Ely's operation for Prominent Auricles. — Tumors. — Angio- 
mata. — Othsematomata. — Perichondritis. — Malignant Growths. — Syphilitic 
Affections. — Erysipelas. — Effects of Gout, 97 

CHAPTER V. 

DIFFUSE AND CIRCUMSCRIBED INFLAMMATION OF THE EXTER- 
NAL AUDITORY CANAL. 

Comparative Frequency of these Affections. — Diffuse Inflammation. — Leeches. — 
Incisions. — Warm Douche. — Fountain Syringe. — Fayette Taylor's Douche. — 
Method of Syringing. — Syringes. — Anodynes. — Desquamative Inflammation. 
— Furuncles. — Local and Constitutional Treatment. — Calcium Sulphide. — 
Lowenburg's Views, ........... 122 

CHAPTER VI. 

PARASITIC INFLAMMATION OF THE EXTERNAL AUDITORY CANAL 
—SYPHILITIC ULCERS AND CONDYLOMATA— CONTRACTIONS- 
DIPHTHERIA— SARCOMA— CARIES. 

History of the Discovery of the Growth of Aspergillus in the External Auditory 
Canal. — Varieties of Vegetable Fungi found in the Ear. — Cases. — Syphilitic 
Ulcers and Condylomata. — Narrowing and Closure of the Canal. — Diphtheritic 
Inflammation. — Sarcoma. — Caries of the Canal, ...... 141 



CONTENTS. XV 

CHAPTER VII. 
INSPISSATED CERUMEN. 

PAGE 

Merely a Symptom of Aural Inflammation. — Frequency of the Affection. — Symp- 
toms. — Reported Cases of Damage to the Ear from the Presence of Wax, prob- 
ably not based on Correct Observation. — Causes. — Treatment. — Cases, . . 156 

CHAPTER VIII. 

FOREIGN BODIES. 

Exaggeration of the Importance of this Subject. — Statistics. — Insects. — Living Lar- 
vae. — Fish. — Inanimate Foreign Bodies. — Treatment. — Delusions as to Foreign 
Bodies in the Ear. — Foreign Bodies in the Eustachian Tube. — Ear Cough, . 177 

CHAPTER IX. 
ANATOMY AND PHYSIOLOGY OF THE MIDDLE EAR. 

Statistics of Diseases of the Middle Ear. — Membrana Tympani. — Shrapnell's Mem- 
brane. — Rivinian Foramen. — Light Spot. — Layers. — Blood-vessels. — Nerves. 
— Lymphatics. — Cavity of the Tympanum. — Scheme for Studying Boundaries 
of this Cavity. — Ossicula Auditus. — Blood-vessels. — Nerves. — Mastoid Pro- 
cess. — Eustachian Tube, Historical Account of. — Physiology of the Middle 
Ear, 211 

CHAPTER X. 

Injuries of the Membrana Tympani. — Diseases of the Membrana Tympani not In- 
dependent Affections. — Vascular, Nervous, and Lymphatic Supply, a Part of 
that of the Canal and Middle Ear. — Drum-head Subject to Injury by Explo- 
sions, Blows, and so forth. — Effects of Condensed Air. — Serious Injuries of the 
Head. — Fracture of the Handle of the Malleus, ...... 257 

CHAPTER XL 

ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 

Nomenclature. — Statistics. — Symptoms. — Treatment. — Leeches. — Paracentesis. — 
Subacute Catarrh. — Hemorrhagic Inflammation of the Middle Ear. — Aural 
Hemorrhage in Bright's Disease. — Vascular Tumors of the Drum-head, . . 276 

CHAPTER XII. 
ACUTE SUPPURATION OF THE MIDDLE EAR. 

A Consequence of Acute Catarrh. — Symptoms. — Causes. — Course. — Cases of Men- 
ingitis Consecutive to Acute Catarrh and Suppuration. — Criticisms upon the 
Modern Antiphlogistic Treatment. — Neurotic Cases. — Treatment and Cases. — 
Acute Serous Inflammation of the Middle Ear, 305 



XVI CONTENTS. 



CHAPTER XIII. 

CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MID- 
DLE . EAR. 

PAGE 

Frequency of this Disease. — Nomenclature. — Catarrh. — Proliferous Inflammation. 
— Subjective Symptoms. — Vertigo. — Tinnitus Aurium. — Insanity. — Subjec- 
tive Symptoms of Proliferous Inflammation. — Objective Symptoms. — Impair- 
ment of Hearing. — Changes in the Membrana Tympani. — -Eustachian Tube.— 
Naso-pharyngeal Inflammation. — Adenoid Growths. —Pathology. — Causes, . 337 

CHAPTER XIY. 

CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MIDDLE 

EAR — ( Continued) . 

Treatment of the Catarrhal and Proliferous Forms. — Constitutional and Hygienic 
Applications to the Naso-pharyngeal Space. — Nasal Douche. — Cases of Acute 
Aural Disease caused by its Use. — Gruber's Method of Cleansing Nares. — Pol- 
itzer's Method. — Anatomy of Nasal Cavities. — Nebulizers. — Faucial Catheters. 
— Removal of the Tonsils. — Treatment through the Eustachian Tube. — Air. 
Steam. — Vapors. — Fluids. — Bougies — Electricity. — Death from Improper 
Use of Catheter. — Duration of Treatment. — Prognosis, ..... 378 

CHAPTER XV. 

THE TREATMENT OF CHRONIC NON-SUPPURATIVE INFLAM- 
MATION— ( Concluded). 

Operations upon and through the Membrana Tympani. — History from 1650 until 
our own Day. — Sir Astley Cooper's Cases. — Schwartze's Statistics. — Politzer's 
Eyelet. — Tenotomy of Tensor-tympani. — Galvano-cautery. — Division of Pos- 
terior Fold. — Prout's Operation. — Hinton's Removal of Accumulations of Mu- 
cus. — Abandonment of Operations by American Otologists. — Condensed Air. 
— Exhaustion of Air. — Weber-Liel and Woakes on Paretic Deafness. — Results 
of Treatment, 412 

CHAPTER XVI. 

CHRONIC SUPPURATION OF THE MIDDLE EAR. 

Consequence of Acute Suppuration. — Otorrhcea an Improper Term. — Often con- 
founded with Chronic Inflammation of the Canal. — Relative Frequency of the 
two Affections. — Symptoms. —Perforations of Membrana Tympani.— Treat- 
ment. — Syringing. — Astringents.— Fluids. — Powders. — Electricity. — Artificial 
Membrana Tympani. — Cases. — Prognosis, .....-• 431) 

CHAPTER XVII. 

THE CONSEQUENCES OF CHRONIC SUPPURATION OF THE 
MIDDLE EAR. 

Chronic Suppuration and its Results Inevitably Dangerous to the Health and Life 
of the Patient. — Refusal of Life Insurance Companies to take Risks of such 
Cases. — Cicatrices and Adhesions in the Tympanum. — Polypi. — Exostoses. — 
Mathewson's Operation for their Removal. — Cases, 468 



CONTENTS. XVI 1 

CHAPTER XVIII. 

THE CONSEQUENCES OE CHKONIC SUPPUEATION OF THE 
MIDDLE EAR— ( Continued) . 

PAGE 

Diseases of the Mastoid Process. — Periostitis. — Caries and Suppuration. — Trei/hin- 
ing or Opening the Mastoid. — Historical Account of the Operation.— Cases, . 401 

CHAPTER XIX. 

THE CONSEQUENCES OF CHRONIC SUPPURATION OF THE MIDDLE 
EAR— {Concluded).— NEURALGIA OF THE MIDDLE EAR. 

Caries and Necrosis of the Temporal Bone. — Cases. — Treatment by Operation and 
Internal Medication. — Fatal Hemorrhage. — Cerebral Abscess. — Pyaemia. — 
Paralysis. — The Ophthalmoscope in detecting Cerebral Disease of Aural 
Origin. — Neuralgia of the Middle Ear, 527 

CHAPTER XX. 

ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 

The Vestibule, Semi-circular Canals, Cochlea, and Auditory Nerve. — Physiology 

of the Internal Ear, ........... 569 

CHAPTER XXI. 

DISEASES OF THE INTERNAL EAR. 

Difficulty in Diagnosis. — Clinical and Pathological Advances. — Differentiation be- 
tween Diseases of Middle and Internal Ear. — Nervousness and Nervous Deaf- 
ness. — Symptoms of Primary Disease of the Cochlea. — Acoustic Neuritis. — 
Atrophy of the Acoustic Nerve. — Cases. — The Tuning-fork in Diagnosis. — 
Deafness to Certain Tones. — Double Hearing. — Electricity. — Syphilitic Dis- 
ease of the Cochlea. — Cochlitis. — Cases, . 590 

CHAPTER XXII. 
DISEASES OF THE INTERNAL EAR— {Concluded). 

The Effects of Quinine. — Cerebro-spinal Meningitis. — Meningitis. — Disease of the 
Spinal Cord. — Parotitis. — Acute Inflammation of Membranous Labyrinth mis- 
taken for Cerebro-spinal Meningitis. — Hemorrhages and Effusions. — Injuries. 
— Concussions. — Aneurism and Tumors. — Disease of Semi-circular Canals. — 
Pathology. — Treatment, 619 

CHAPTER XXIII. 
DEAF-MUTEISM— MECHANICAL ASSISTANCE TO THE HEARING. 

Acquired and Congenital Cases. — At what Age are Children Conscious of Sounds ? 
— Causes. — Tables of Examination of 147 Cases. — Hearing-trumpets. — Audi- 
phone, 663 

DESCRIPTION OF THE CHROMO-LITHOGRAPHS, .... 700 

INDEX OF AUTHORS, 70;* 

GENERAL INDEX, 709 



LIST OF WOOD-CUTS. 



FIG. PAGE 

1. Tuning-fork, .....-,. 54 

2. Blake's Tuning-fork, . 57 

3. Angular Forceps, 59 

4. Grubers Speculum, 60 

5. Method of holding the Speculum in Position, 61 

6. Method of Examining the Auditory Canal and Membrana Tyinpani, . . 62 

7. Collin's Lamp, . . 63 

8. Forehead Band, 63 

9. Blake's Operating Otoscope, 65 

10. Hinge Speculum, . 66 

11. Turck's Speculum, 66 

12. Anterior Nares Speculum, 68 

13. Goodwillie's Nasal Speculum, . . 68 

14. Eustachian Catheters, actual size, ......... 70 

15. Introduction of Eustachian Catheter, . . . . . . .71 

16. The Eustachian Catheter in Position, 72 

17. Air-bag, . . .73 

18. Diagnostic Tube, . 73 

19. Method of Using Politzer's Apparatus (with box for containing iodine or other 

evaporating substance), ........... 75 

20. Dr. Allen's Nose-pads for Politzer's Apparatus, 76 

21. The Auricle, • 81 

22. Profile View of the Skull with the Skeleton or Cartilage of the Auricle, as 

well as that of the External Auditory Canal, 82 

23. Muscles of the External Ear, • . . .85 

24. View of the Cartilage and Muscles on the Posterior Surface of the Auricle, 86 

25. The Muscles of the Head, 90 

26. Section through the External Meatus and the Ear at the Point of Junction of 

the Cartilage of the Auricle with that of the Auditory Canal, . . .91 

27. Horizontal Section of the Head through the External Auditory Canal, . . 92 

28. Annulus Tympanicus, 92 

29. Cast of Auditory Canal and Adjacent Parts, 93 

30. Section of Left Temporal Bone, 93 

31. External Surface Left Temporal Bone, 95 

32. Case of Prominence of Auricles (front view), ....... 98 

33. Case of Prominence of Auricles (posterior view), ...... 99 

34. 35. Deformity of Auricles, 101 

36. Othaematoma. From a photograph taken from a plaster cast when the tume- 

faction was greatest, . 108 

37. The same Ear after Rupture and Contraction had taken place, . . . 108 



XX LIST OF WOOD-CUTS. 

FIG. PAGE 

38. Showing Amount of Contraction after Rupture of Cyst, 109 

39. Shows Separation of Perichondrium from Cartilage, 109 

40. Auricle Deformed by Inflammation, . 113 

41. Tumor of the Anterior Part of Auricle and Auditory Canal, .... 117 

42. Improved Fountain Syringe, 127 

43. Fayette Douche, 128 

44. Syringe for the Ear, 132 

45. Reservoir Syringe, 132 

46. Method pf Syringing the Ear, 133 

47. Aspergillus Nigricans, 145 

48. Aspergillus Flavescens, 146 

• 49. Specimen of the Spores and fully developed Growth of the Aspergillus Fla- 
vescens, 147 

50. Penicillium, 148 

51. Otomyces Purpureus, 148 

52. The Right Temporal Bone, without the Petrous Portion in connection with 

Ossicula Auditus of a Newly-born Child, seen from within, . . . 212 

53. Left Temporal Bone of the same Subject as preceding figure, ... . 212 

54. Section through Tympanic Cavity, Left Side, 213 

55. 56. View of Membrana Tympani, showing Handle of Malleus and Trian- 

gular spot of Light, 217 

57. Vertical Section of Fibrous Layer of the Membrana Tympani, . . . 319 

58. The Membrana Tympani, in connection with the Ossicula Auditus of the 

Right Temporal Bone, . 223 

59. Temporal Bone of Left Side (inner view), ; 224 

60. The Right Temporal Bone, with the Membrana Tympani and Ossicula Au- 

ditus of an Adult, . 227 

61. Section of Right Temporal Bone, 228 

62. Section through Tympanic Cavity, Left Temporal Bone, . . . . 229 

63. Tympanic Cavity with Ossicles in situ, . . . . . . . . 230 

64. Anterior Surface of Malleus and Incus Articulated, 230 

65. Ossicles of the Tympanum, 231 

66. Posterior Surface of the Malleus, Incus, and Stapes Articulated, . . . 231 

67. Vertical Section through the Right Temporal Bone, 237 

68. External Surface of Left Mastoid Bone, .238 

69. Vertical Section through Right Temporal Bone, 239 

70. Vertical Section of Left Temporal Bone, 240 

71. Section of the Head, showing the Divisions of the Ear and Naso-pharyngeal 

Cavity, 242 

72. Transverse Section of Upper Part of the Eustachian Tube, .... 243 

73. Transverse Section through Lower End of the Eustachian Tube, . . . 244 

74. Same as last, . . ' 244 

75. Vertical Section, showing the Mouth of Eustachian Tube and Rosenmiiller's 

Fossa, 245 

76. Transverse Section of Eustachian Tube and Surrounding Parts, . . . 246 

77. Section of the Upper Third of the Eustachian Tube, . . . v . .247 

78. Section of the Middle Third of the Eustachian Tube, 248 

79. Fracture of Handle of Malleus, displaced, . . . . . . . 275 

80. Fracture of Handle of Malleus, reduced, ....... 275 

81. Paracentesis Needle, . . . . 287 

82. Diseases of Bone in Case of Meningitis following Acute Suppuration of Mid- 

dle Ear, 313 



LIST OF WOOD-CUTS. XXI 

FIG. PAGE 

83. Seigle's " Otoscope " with. Ely's Attachment of a Syringe, .... 366 

84. Pharyngitis Granulosa, 368 

85. Posterior Nares Syringe, ....... ... 381 

86. Davidson's Syringe with a Nozzle to go below the Soft Palate, . . . 382 

87. Vertical Section of Bones of Face (posterior half), 386 

88. Vertical Section of Bones of Face (anterior half), 388 

89. Nebulizer for Nostrils and Pharynx, 390 

90. Tonsil Knife, 393 

91. Tonsil Forceps, 393 

92. Apparatus for Steaming the Middle Ear, 396 

93. Bottle for the Generation of Vapor of Iodine. An ordinary air-bag is used 

for forcing the vapor into the catheter, 397 

94. Hackley's Eustachian Nebulizer, 401 

95. Prout's Knife, . . . . . ' 430 

96. Vessel Used in Syringing the Ear, ......... 450 

97. Buck's Pipette, . 451 

98. Knapp's Powder-blower, .......... 453 

99. Toynbee's Artificial Membrana Tympani, f 461 

100. Method of Inserting Artificial Membrana Tympani (Toynbee), . . . 462 

101. Section of Aural Polypus, . . . 471 

102. Section of Aural Polypus, 472 

103. Section of Aural Polypus, 473 

104. Blake's Modification of Wilde's Snare with Paracentesis Needle, . . . 476 

105. Scissors for the Removal of Aural Polypi, ....... 476 

106. Buck's Curettes for Clearing Auditory Canal and Tympanum, . . . 477 

107. Schwartze's Chisels for Opening the Mastoid, 502 

108. Left Temporal Bone, Exterior View (Necrosis), 531 

109. Left Temporal Bone, Inner Surface, ........ 531 

110. Left Temporal Bone, Sawed through External Meatus, Middle Ear, and 

Cochlea 532 

111. Bight Temporal Bone, from Case V., showing the Cranial Surface of the 

Bone, 533 

112. Caries of Squamous and Mastoid Portion of Temporal Bone, .... 534 

113. Caries of Petrous Portion of Right Temporal Bone, 535 

114. Caries of Lateral Sinus of Right Temporal Bone, 536 

115. Caries of Squamous Portion of Temporal Bone, ... . . . . 536 

116. A Diagram designed to show the Relations of the Tympanic Cavity to the Mas- 

toid Cells, the Jugular Fossa and the Cavity of the Cranium, . . . 538 

117. The Left Vestibule, with the Semi-circular Canals, from an Adult, seen from 

within, 570 

118. The Vestibule, 570 

119. Section of Temporal Bone of Right Side through the Cochlea, . . . 572 

120. Osseous Cochlea and Semi-circular Canals with Stapes Bone, Left Ear of 

Adult, . 572 

121. Right Osseous Vestibule, Semi-circular Canals, Cochlea, and Ossicula Auditus 

of Newly Born, ............ 572 

122. The Right Osseous Labyrinth of a Newly Born Subject, opened on its Poste- 

rior Surface, . . ' 573 

123. Section of Right Temporal Bone, showing the Osseous Semi-circular Canals, . 573 

124. Osseous Cochlea (Right) of the Newly Born, opened from the Outer Surface, . 574 

125. Section through Cochlea and Vestibule, 575 

126. Periosteum of Labyrinth, 570 



XX11 



LIST OF WOOD-CUTS. 



127. Periosteum of trie Outer Wall of the Cochlea, .... 

128. Utricle and Membranous Semi-circular Canals of the Left Side, 

129. A Piece of the Wall of the Utricle, with the Otoliths, 

130. Transverse Section of a Cochlea Spiral, . 

131. From the Terminal Auditory Apparatus of a Cat, . 

132. Profile View of Outer and Inner Rods, . 

133. Membrana Basilaris, with the Terminal Nerve-Fibres, 

134. Expansion of the Right Cochlea Nerve, seen from the Base of the Cochlea, 

135. A Diagram designed to Illustrate the Physiology of the Labyrinth, 

136. Hearing-trumpets, ........... 

137. Auricles, 

138. The Audiphone in its Natural Position, used as a Fan, .... 

139. The Audiphone in Tension, the Proper Position for Hearing, 

140. Method of using the Audiphone, 



PAGE 

576 

577 

577 

579 

581 

, 582 

, 582 

, 583 

586 

. 697 

. 697 

. 698 

. 698 



A TEEATISE ON 

THE DISEASES OF THE EAR 



CHAPTER I. 

A SKETCH OF THE PEOGRESS OF OTOLOGY WITH A BIBLI- 
OGRAPHY. 

Vastness of Otological Literature. — Apathy in regard to Diseases of the Ear. — Wilde 
the Reformer of the Science. — Carl Gustav Lincke and his Handbook. — Papyrus 
Ebers. — Hippocrates and his Knowledge of the Ear. — Alcmseon the Discoverer of 
the Eustachian Tube. — Rufus of Ephesus. — Aristotle. — Discoveries in the Time of 
the Ptolemys. — Galen and the Want of Progress in his Time. — Achillini and Beren- 
gario describe the Ossicles. — Vesalius the most accurate Anatomist of his Day. — In- 
grassia, Columbo, and Eustachius each claim Discovery of Stapes. — Fallopius and 
his Career. — Anatomical Writings of Eustachius. — First Monograph on Anatomy of 
the Ear. — Constant Varolius. — Fabricius of Aquapendente. — Valsalva. — Casserius, 
a Pupil and Rival of Fabricius. — Stenon describes Ceruminous Glands. — Discovery 
of Helicotrema. — Du Verney and his Plates. — Cotugno and the Aqueducts. — 
Meckel. — Rivinian Foramen. — Hyrtl and Bochdalek upon its Existence. — Ruysch. 
— Brendel and Zinn. — Scarpa upon the Internal Ear. — Saunders, Todd, and others. 
— Monro's Claim to have first traced the Nerves into the Cochlea, Vestibule, and 
Semicircular Canals. — Everard Home's Account of the Membrana Tympani. — 
Soemmering. - Shrapnell. — Thomas Buchanan on the Importance of Cerumen. — 
Wharton Jones. — Discoveries of Toynbee. — Troltsch, Politzer, Lucse, and others. 
— The Organ of Corti and its Discoverer. — Pathological Anatomy of the Ear. — Prog- 
ress in Treatment of Aural Disease. — Herodotus on Specialists. — The Remedies 
suggested by Hippocrates. — Celsus. — Archigenes on Venesection and Foreign 
Bodies. —Galen on Noise. — Peculiar Method of removing Foreign Body from Ear. 
— Paulus iEgineta,his Classification and Operation. — Arabians, their Knowledge of 
Otology. — Paracelsus burning Books of his Predecessors. — Capivacci on Differential 
Diagnosis — Ambroise Pare first uses a Syringe for the Ear. — The Education of 
Deaf Mutes. — Old Method of detecting Inspissated Cerumen. — Lusitanus on cut- 
ting off Ears of Thieves. — Fabricius of Hilden. — Thomas Willis, his Observations 
on Hearing in a Noise. — The Therapeutical Work of Valsalva. — Petit on Caries of 
the Mastoid. — The Discovery of the Eustachian Catheter. — Guyot, Cleland. — Per- 
foration of the Membrana Tympani. — Trephining the Mastoid. — Sir Astley Cooper. 
— Saunders on Perforation of the Membrana Tympani. — First Infirmary for Dis- 
1 



2 A SKETCH OF THE 

eases of the Ear. — Saissy, Itard, Beck. — Sketch of Kramer's Career. — Discovery of 
Artificial Mernbrana Tympani. — Yearsley. — Wilde and his great Work in Otology. 
— The Text-books of Toynbee, Troltsch, Erhard. — Modern Text-books and Jour- 
n als. — Bibliography . 

There is perhaps no department of the art and science of medi- 
cine, in which there has been so much literature, with so little 
exact, or as we say, scientific knowledge, as that which was 
formerly known as aural medicine and surgery, but which is 
better designated by the term Otology. 

Hundreds and perhaps thousands of volumes have been 
written on the anatomy, physiology, and diseases of the ear, 
and yet until the age of Valsalva, the seventeenth century, the 
treatment of the affections of the organ of hearing was purely 
empirical, while the knowledge of its anatomy and physiology 
was generally incorrect and superficial. Even after the inves- 
tigations of the famous Italian, investigations which occupied 
sixteen years of his life, and the subsequent anatomical dis- 
coveries of the eighteenth century, it was reserved for our own 
day and generation to place the science of otology, or the knowl- 
edge of the anatomy, physiology, and diseases of the ear, on a 
level with that of other fields of labor in medicine. 

A singular apathy in regard to the maladies of one of the 
most important organs of the body, an inexplicable ignorance 
as to their results, a most irrational and empirical manner of 
treatment, have been our heritage from the fathers. Probably 
to-day, in the closing years of the nineteenth century, aural 
medicine and surgery is more generally regarded from the 
standpoint of the errorists of the dark ages, than is any other 
department of our science and art. It is to be feared, that even 
now, many wise and skilful practitioners do not know, that to 
drop stimulating or even anodyne applications upon a membrane 
which they have never examined, to probe an ear for wax that 
they cannot see, are purely empirical practices which every con- 
scientious physician should hold in abhorrence. 

The great reformer of this science, Wilde, 1 wrote, as late 
as 1853, that "the affections of the ear, whether functional or 
organic, are spoken of, lectured on, written of, and described 
(even in great part to the present day), not according to the laws 
of pathology which regulate other diseases, but by a single symp- 
tom, that of deafness.' 7 

It is with no desire to recount the details of the long and 
painful story of the gropings in the dark, which have charac- 
terized the teachings on otology from the days of the philoso- 

1 Aural Surgery, English edition, p. 7. 



PROGRESS OF OTOLOGY. 6 

pher of Cos, until the seventeenth century, that I attempt an 
historical sketch of our progress up to our present position. I 
have neither the time nor the facilities for such a task ; but an 
endeavor will be made to sketch the history of otology, from the 
sources to which I have access, in such a manner as to show 
the obstacles which, until twenty years ago, have prevented 
the satisfactory progress of the science. 

I must first of all, make especial acknowledgment of my in- 
debtedness for a large part of my material, to that valuable com- 
pendium, "Lincke's Handbuch der Ohrenheilkunde." ' I have, 
however, consulted the original authorities as far as the best 
medical library of New York — that of the New York Hospital — 
and my own would permit. Where no other authority is given in 
a foot-note, Lincke is the one from which I quote, and often by an 
exact translation. The discoveries and teachings in the anatomy 
of the ear will be first reviewed, after which the progress in the 
examination and treatment of its diseases will be noted. 

For the convenience of the reader, I have given the titles of 
the works consulted, both at the foot of the page, and in the for- 
mal bibliography. 

In the Astor Library in the city of New York, is a fac-simile 
copy of one of the oldest medical treatises that is known to ex- 
ist. The original is a papyrus book in the Royal Saxon Library 
of Leipsic. It is called the " Papyrus Ebers," it having been ob- 
tained by the celebrated Egyptologist, George Ebers, while in 
Thebes, from a certain native, who is said to have taken it, about 
the year 1861, from among the bones of an Egyptian who had 
been buried more than thirty-four hundred years. This book is 
entitled "The Hermetic Book of the Medicines of the Ancient 
Egyptians." 2 It is written upon papyrus, three-fourths of a 
meter wide and twenty meters long. It is one of the six medical 
works named by Clement of Alexandria. 

Among other subjects treated of in this large volume, is a 
monograph upon " medicines for ears hard of hearing," and " for 
ears from which there is a putrid discharge." Inasmuch as the 
translation of the hieroglyphic language of the manuscript only 
extends, as yet, to the table of contents, we cannot know whether 
the Egyptian priests had a better knowledge of the proper treat- 
ment of the ear, than was possessed by their Greek and Roman 
successors many centuries later. 

1 Carl Gustav Lincke was a teacher of otology in the University of Leipsic from 
Easter, 1837, to Easter, 1840. His name appears in the catalogue of that University in 
the sessions of 1845-46 for the last time. 

• Papyrus Ebers. Das Hermetische Bucli liber die Arzneimittel der alten Aegypten. 
Leipzig, 1875. 



4 A SKETCH OF THE 

A papyrus of later date is in the Berlin Museum. This has 
been translated by Dr. G. Brugsh, 1 and there are also similar 
manuscripts in the museums in Ley den, London, and Turin. 

PROGRESS IN THE ANATOMY OF THE EAR. 

Hippocrates probably knew very little of the anatomy of the 
ear, although one passage is found in his works which indicates 
that the membrana tympani was not unknown to him. 2 

Alcmseon, a disciple of Pythagoras (570-504 B.C.), is said to 
have had a knowledge of the art of dissecting the human body, 
to have known the construction of the ear, and to have antici- 
pated Eustachius in the discovery of the passage leading from 
the tympanic cavity to the pharynx. Lincke thinks that this 
much cannot be conceded to Alcmseon, since it rests only upon 
his assertion, brought forth and denied by Aristotle, that goats 
breathed through their ears. " This statement of Alcmseon is said 
to have rested upon other grounds than the existence of what 
we call the Eustachian tube. Plutarch says, however, that 
Empedocles discovered a snail-shaped cartilage in the ear 
(koxA.iwS>7s x ov ^P 0S )j which he considered the real organ of hearing, 
and that the vibrations of the air caused it to give forth a tone 
which was then perceived by the soul. 

The knowledge of Aristotle (384-322 B.C.) as to the anatomy 
of the ear did not go beyond the membrana tympani. But Aris- 
totle made numerous dissections of animals and many impor- 
tant discoveries in anatomy. There are indications that he had 
an indefinite idea of the Eustachian tube. 

In the time of the Ptolemys in Egypt, when dissections of 
the human body were instituted, Erasistratus made the discovery 
that the nerves originate in the brain, and he traced them so 
exactly to their origin that we find the acoustic nerve properly 
indicated in his representations. 

Rufus of Ephesus (a.d. 98-117), who was the first medical 
lexicographer, and who lived in the age of Pliny, 3 used the names 
helix, lobe, tragus, and anti-tragus, which are still employed to 
describe the different parts of the auricle. He probably obtained 
them from Herophilus, a contemporary of Erasisn'atus. 

Marinus, the preceptor of Galen, and whom Galen named 

1 Hartmann : Lehrbuch, Einleitung. 

2 Tb Sep/xa rb irpbs rrj clkot) 

irpbs r£> vcrreco tw aKX-qpw Xeirrbv 
iariu &arrep apayyiov, ^rjpora rov 
rod oWou Sep/xaros. 

3 History of Medicine (Dunglison), p. 16ft 



PROGPwESS OF OTOLOGY. 

the restorer of anatomy, called the acoustic and facial nerves 
one, under the name of the fifth pair. 

Galen (a.d. 130-200) does not seem to have made any great 
advance in anatomical studies, and they were greatly neglected 
down to the fifteenth century. The darkness of the blind lead- 
ing the blind is scarcely broken for thirteen hundred years. 
What Galen wrote, was authority, and naught else. One valiant 
and polemic skeptic in medicine, would have effected more good 
during these centuries than all the ponderous tomes that were 
written by philosophers who reasoned upon premises that had 
never been thoroughly established. As late as 1550, one Doctor 
Geynes was called before the College of Physicians in London 
for impugning the fallibility of Galen. On his acknowledgment 
of his error, however, he was again received into the college. 1 
The strong arm of the church, in the dark ages, prevented ana- 
tomical investigations on the human cadaver, and for hundreds 
of years anatomical knowledge remained at a standstill. 

Galen, however, corrected the error of his preceptor in think- 
ing that the facial and acoustic nerves were one, and showed 
that the latter entered the meatus audit orius internus, a passage 
which his predecessors had regarded as impermeable. He gives 
no account of the anatomy of the internal ear, although he com- 
pares it to a labyrinth, a name which Fallopius, fourteen hun- 
dred years later, fastened on it forever. He believed that the 
external auditory canal extended to the dura mater and touched 
the auditory nerve. 

There is no record of the ossicula auditus until the fifteenth 
century. An Italian anatomist, Alexander Achillini, generally 
has the credit of discovering the little bones, but it is probable 
that he and Jacob Berengario first described them, although 
they did not discover them. This is the opinion of the great 
anatomist, Bartholomeo Eustachio. The discovery of the ossi- 
cula auditus did not at first include the third and last of the 
chain. 

Berengario also first described the membrana tympani ••with 
exactness." The exactness of his knowledge, may be shown by 
the fact, that he was doubtful whether the origin of the mem- 
brane was in the acoustic nerve or the meninges of the brain. 

Andreas Yesalius (1514-1564), who is said to have been the 
most accurate anatomist of his day, 2 described the long process 
of the malleus, the Eustachian tube, the vestibule, and the semi- 
circular canals. He was a reformer in anatomical learning, he 

1 Chambers's Encyclopedia, American edition. Article, Galenus or Galen. 

2 Dnnglison : History of Medicine. 



6 A SKETCH OF THE 

boldly attacked the views of Galen, showing the errors in his 
teachings. His anatomical plates were made from drawings by 
the best masters. They were published in a folio edition at 
Basle in 1542. 

The honor of the discovery of the stapes bone is claimed by 
no less than three anatomists, viz. : Ingrassia, Columbo, and 
the renowned Bartholomeus Eustachius (1604). The first named 
wrote commentaries upon Galen's works, that were published 
long after his death. He claims to have shown the bone to his 
scholars in 1546, at Naples. Fallopio, or Fallopius, at one time 
claimed to have had a part in the discovery of the ossicle, but 
in view of his own greater discoveries he finally relinquished his 
claim in favor of Ingrassia, after one of the latter's pupils had 
assured him, that Ingrassia had actually discovered and named 
the bone. The weight of evidence, in spite of the opinion of 
Eustachius, seems to lean toward the side of Ingrassia as having 
the honor of the discovery. Anatomical and geographical sci- 
ence were about this time in an embarrassed position from the 
claims of priority of their discoverers. Fallopius did good ser- 
vice, in the study of the anatomy of the ear, in describing the 
tympanic cavity more accurately, the two fenestrse, and their 
communication with the vestibule and the cochlea respectively. 

The anatomical writings of Eustachius were published in 1563, 
before his death, but the Tabulce Anatomicce did not appear un- 
til 1714, a century and a half afterward. He was probably unable 
to publish these on account of his poverty. Of posthumous fame 
he has had a large share. His anatomical plates were repro- 
duced with Dutch and German commentaries — in the latter 
language as late as 1800. The Venetian edition of his works is a 
beautiful specimen of printing. The part referring to the ear 
occupies only seventeen pages — yet his fame now rests chiefly 
upon his description of the Eustachian tube. 1 

Gabriel Fallopius (1523-1562), of Modena, died in the bloom 
of youth, at thirty-nine years of age, 2 but he lived long enough 
to accomplish much for anatomical science. He showed, among 
other valuable points in the anatomy of the ear, that the mastoid 
cells communicated with the cavity of the tympanum. He de- 
scribed the fenestrse rotunda and ovalis, and gave his name to 
the canal in which the facial nerve runs in its passage through 
the cavity of the tympanum — acquceductas Fallopii. 3 

The great Cuvier regarded Vesalius, Eustachius, and Fallo- 

1 Bartholomsei Eustacliii : Opuscula Anatomica Anatomica, MDLXIII. 

2 Chambers's Encyclopaedia, p. 233. 

3 Gabrielis Falloppii : Cpera Omnia. Francfurti, MDC. 



PROGKESS OF OTOLOGY. 7 

pius as the three anatomists of the sixteenth century, to whom 
belongs the honor of having restored this science. 

Bartholorneo Eustachio (1500-1574) described the tensor tym- 
pani as well as the stapedius muscle. He also gave a more ex- 
act account of the tube leading from the pharynx to the middle 
ear, which is called the Eustachian tube, although it was dis- 
covered by Vesalius. He described the modiolus of the cochlea, 
and gave a good representation of the membranous zone. He 
also recognized the three portions of the facial nerve. 

The first monograph on the anatomy of the ear was from the 
pen of Volcher Koiter (1587), a student of Fallopius. It con- 
tained no original observations, however. 

Constant Yarolius (1543-1573), * so well known from his de- 
scriptions of the brain, made the singular mistake of supposing 
that the muscles of the cavity of the tympanum were nerves 
which were torn by the sawing through of the bone. Subse- 
quently he admitted this error ; but he went so far to the other 
side, as to say that the tensor and laxator tympani muscles could 
be moved at will. 

Lincke does not think that the famous Fabricius of Aquapen= 
dente (1537-1619) contributed very much to our knowledge of 
the anatomy of the ear, while he led many away into error as 
to some points. For example, he thought that the chorda tym- 
pani nerve was a peculiar body, and not a nerve. At any rate, 
Fabricius did good service by his labors as a comparative anato- 
mist, and it should be remembered that he was the instructor of 
the discoverer of the circulation of the blood. 

The folio edition of his works, published in 1600, 2 contains a 
very systematic and clear account of the anatomy of the ear as 
then understood. He gives the name myrinx, as well as my- 
ringa — whence our myringitis — to the membrana tympani. Fa- 
bricius ascribes the discovery of the Eustachian tube to an 
earlier date than that which assigns it to Eustachius. Accord- 
ing to him Aristotle knew of it. 

Julius Casserius (1593-1609), who was a professor in Venice 
in 1609, a pupil and subsequently a rival of Fabricius, described 
the fissures that make the cartilaginous portion of the canal so 
flexible. He and Fabricius described the laxator tympani minor 
in the same year, and both claim to have discovered it first. 
Casserius also gave a better description than had hitherto been 
done of the membrana tympani, the ossiciila auditus, and the 
labyrinth. He was the first to describe the two and a half 
turns of the cochlea and the membranous zone. 



1 Biograpliie Medicale. Paris. 

2 Heronyrni Fabricii ab Aquapendente. De Visione, Voce, Audita. Venetiis, 1600. 



8 A SKETCH OF THE 

The function and physiological action of the ceruminous 
glands were first described by Mcolaus Stenon (1665). Lincke 
speaks of him as Stenson ; but this must be a mistake in tran- 
scribing the name of the great Danish anatomist. 

Lincke ascribes to Du Verney the greatest reputation of any 
of the anatomists of the seventeenth century who devoted any 
attention to the ear. He threw new light upon many dark sub- 
jects. He was the first to give good representations of the ceru- 
minous glands, the Eustachian tubes, and the semicircular 
canals with their five openings in the vestibule. 5 His plates are 
particularly clear. 

Passing on to the eighteenth century, we find Antonine Marie 
Valsalva rising up a head-and-shoulders above the anatomists of 
his age, and far exceeding his predecessors in the amount and 
exactness of his knowledge. He devoted more than sixteen 
years of his life to the study of the anatomy of the ear, and for 
the purpose of its study dissected more than a thousand heads. 
His master-work was a treatise on the ear. 2 This work passed 
through five editions in a short time. He described the attach- 
ment of the tensor tympani to the Eustachian tube. He made 
the mistake, however, of supposing that the ossicula auditus 
had no periosteum, and that the cavity of the tympanum was 
connected by many openings to the cavity of the cranium. He 
discovered the muscle that opens the Eustachian tube and moves 
the uvula. He also showed that the fenestra ovalis was covered 
by membrane. His anatomical plates show a good knowledge 
of the cochlea and semi-circular canals. 

Morgagni (1682-1771), himself an original investigator, the 
founder of pathological anatomy, a student and friend of Val- 
salva, edited his master's work and made some additions. 

Of Valsalva's contributions to the treatment of the ear, 
which were quite as important as his anatomical investigations, 
we shall have occasion to speak in the second part of this sketch. 
Valsalva had a rival, whose name the lapse of time has well 
nigh effaced, Raymond Vieussens (1714), who also wrote a work 
on the ear. He gave new names to various parts of the organ ; 
but his descriptions are said by Lincke, to be so mysterious that 
his contemporaries could not understand them. 

Rivinus (17i7), professor in Leipsic, observed an opening in 
the membrana tympani, which he believed to be a constant ana- 
tomical condition. This supposed discovery excited the warm- 

1 Tractatus de Organo Auditus, par Dr. du Verney. Noremberga?, 1684. 

2 Tractatus de Aure Humana. Lugdunum Batavoruni, 1742. Also, the same. 
Trajecti ad Rlienum, 1717. 



PROGRESS OF OTOLOGY. 9 

est discussion among such anatomists as Walther, Ruysch, 
Morgagni, Cassebohm, and Valsalva. Hyrtl, until recently the 
distinguished anatomical teacher of Vienna, thought that it was 
a rent in a macerated membrane ; but his predecessor, Berres, 
believed in its existence and described it minutely. 1 

Professor Bochdalek, of Prague, has revived the question, 2 
and has described the foramen of Rivinus as a constant opening 
in the membrana tympani ; this author says that there are some- 
times two. It is, however, according to Bochdalek, so small as 
not to be seen without the aid of a magnifying glass. 

In a discussion in one of the medical societies of Vienna, 3 
Professors von Patruban, Gruber, and Politzer unite in affirm- 
ing its existence, thus confirming Bochdalek's statement. 

The famous Ruysch (1718) (Frederick), professor in Amster- 
dam, contributed to our knowledge of the distribution of the 
vessels of the cavity of the tympanum, and corrected Valsalva's 
statement that the ossicula were not covered by periosteum. 

Cassebohm (1730) (Joan. Frid.) published a monograph upon 
the ear, in six parts, which Lincke calls " a monument to Ger- 
man industry and German spirit of inquiry." "EinDenkmal 
deutschen Fleisses und deutschen Beobachtungsgeistes." He 
disproved Valsalva's idea of the close connection between the 
cavity of the tympanum and the cerebrum ; he described the 
cochlea and the development of the auditory apparatus in 
the foetus. 

Brendel and Zinn (1747-1753), two Gottingen anatomists, the 
latter of whom is well known as the describer of the suspensory 
ligament of the lens, known as the zonula of Zinn, made further 
investigations as to the structure of the cochlea. 

Brendel discovered the opening uniting the two scala?. the 
helicotrema of Breschet. Zinn describes the opening through 
which the auditory nerve enters the cochlea. 

It is claimed, in an inaugural thesis published in Erlangen in 
1754, that Casimir Christopher Schmiedel, discovered the so- 
called Jacobson's nerve. 

Dominic Cotugno (1761), the discoverer of the fluid of the lab- 
yrinth, won such a reputation by his work upon the internal 
ear that he was called to the anatomical chair at Naples. He 
was the first clearly to show that the labyrinth was filled with 
fluid, and that this was one of the necessities for the perception 
of sound. He described two canals, one opening in the vesti- 



1 Prager Viertel. Jalirsclirift, 18GG, I. 

? Troltsch on the Ear, 2d American edition, p. 26. 

3 Monatsschrift fur Ohrenheilknnde, Jahrgang III., No. I. 



10 A SKETCH OF THE 

bule, the other in the cochlea, and both communicating with the 
cerebral cavity. They were named in his honor. 

Phil Friederich Meckel confirmed and corrected the observa- 
tions of Cotugno by injections of quicksilver. 

Antonio Scarpa (1747-1832), nearly thirty years after the pub- 
lication of Cotugno's writings, issued a work on the structure 
of the ear, which brought the knowledge of its inner arrange- 
ment to such a height, that it seemed to his contemporaries that 
there was little more to be done. The investigations of our 
own day have shown how premature was this expression. 
Scarpa wrote upon the fenestra rotunda, which connects the 
tympanic cavity with the lamina spiralis of the cochlea. He 
described the osseous labyrinth with exactness, the membra- 
nous labyrinth, and the expansion of the acoustic nerve. 

Scarpa was secretary to the octogenarian Morgagni, when 
the latter had lost his sight, and he wrote letters of advice in 
Latin at the dictation of his blind preceptor. His beautiful cop- 
per-plate representations of the ossicles in situ, are somewhat 
diagrammatic, but they are almost as instructive as the accu- 
rate photographs of Eudinger of our own day. Those of the 
semi-circular canals remain in some respects unsurpassed. 

Saunders, Van der Hoeven, Alex. Fischer, Teole, and David 
Todd (1806), also contributed essentially to complete our knowl- 
edge of the anatomy of the ear. 

Alexander Monro 1 (1797), "Professor of Anatomy, Medicine, 
and Surgery " in the University of Edinburgh, was the author 
of a monograph on the organ of hearing in man and other ani- 
mals. It is a fine specimen of typography. In his preface he 
states that Dr. Camper called in question his description of the 
semi-circular canal in whales, and that Scarpa said that some of 
his teachings in regard to the human ear were erroneous. Pro- 
fessor Monro, claims to have been the first anatomist to trace the 
auditory nerve within the cochlea, vestibule, and semi-circular 
canals. He quotes from Valsalva, Winslow, Cassebohm, Haller, 
Cotunnius, Meckel, and others, to show that none of these anat- 
omists had traced nerves into the cochlea. Dr. Monro seems to 
make out a good case for himself as against Scarpa, as far as I 
have been able to determine, and to be entitled to the credit of 
having traced the nerves into the cochlea, before and with greater 
minuteness than Scarpa, and he appears to have been correct in 
his comparative anatomy. 

Sir Everard Home (1800) wrote an excellent, and, for its time, 
exact account of the membrana tympani in a paper for the Royal 

1 Three treatises on the Brain, the Eye, and the Ear. Edinburgh and London, 1797. 



PROGRESS OF OTOLOGY. 11 

Society. 1 The measurements are accurately given, but Mr., 
Home supposed that the fibrous layer was muscular. He seems 
to have been a comparative anatomist of great ability. 

Samuel Thomas Soemmering (1806), a great name in anatom- 
ical science, contributed to otology by a series of plates of the 
anatomy of the ear," which are almost as well worth study to- 
day as they were seventy years ago. 

Henry Jones Shrapnell (1832) contributed a series of papers 
to the London Medical Gazette.'' He described the membrana 
flaccida of the drum-head, its nerves, with clearness and accu- 
racy. His description of the former is available for the student 
of the present time, and Shrapnell's membrane is probably firmly 
fixed in the nomenclature of the anatonry of the ear. 

Thomas Buchanan (1832), of Hull, brought out a monograph 
illustrative of the anatomy and diseases of the ear. His ideas 
as to the importance of the cerumen produced many errors in 
treatment, from which the profession has not yet fully recov- 
ered. He published four works ; the title of the last one illus- 
trates what has just been said : " Physiological Illustrations of 
the Organ of Hearing, more particularly of the Secretion of 
Cerumen, and its Effects in rendering Auditory Perception Acute 
and Accurate." 4 

The distinguished English surgeon, T. Wharton Jones, Esq. 
(1836-39), contributed to a great cyclopaedia an article on the 
organ of hearing, which comprised all that was known up to 
that time, and which is a very valuable monograph for refer- 
ence. 5 

We are now, in our review of the investigations of the anat- 
omy of the ear, down nearly to our own time ; and we come to 
the familiar names of Huschke, Arnold, Schlemn, Johannes 
Muller, Breschet, Bonnafont, and Toynbee (1824-51). 

Huschke, and especially Breschet, examined the labyrinth 
more thoroughly. Breschet called attention to much that was 
incorrect in anatomical nomenclature. Bock, Jacobson, Arnold, 
Schlemn, and Muller greatly increased our knowledge of the 
different nerve-tracts. The anatomical and physiological text- 
books of Breschet, J. F. Meckel, Weber, Cloquet, and others, 
added much to the common stock of anatomical knowledge. 

1 Philosophical Transactions, 1800. The Croonian Lecture. 

5 Samnelis Thomre Soemmering : Icones Organi Auditus Humani. Francof urti ad 
Mcenum, 1806. 

3 Vol. x., 1832. 

4 Mr. Wilde on the early history of Aural Surgery. Dublin Medical Journal, 1S44. 
p. 441. 

5 Cyclopedia of Anatomy and Physiology. Edited by Robert B. Todd. 



12 A SKETCH OF THE 

These authors grouped and assimilated facts that the centuries 
had produced, and added not a few, as the result of their own 
labors. 1 

Toynbee 2 (1851) investigated anew the membrana tympani. 
He especially added to our knowledge in regard to the fibrous 
layer, and described, for the first time, the dermoid layer. This 
paper was published in the ''Philosophical Transactions." It 
was preceded by papers in the " Medico-Chirurgical Transac- 
tions,'' on the pathological anatomy of the ear, papers which 
have given Toynbee lasting fame, because they did very much 
to place otology upon as sound a basis in pathology, as that it 
had obtained in anatomy, by the labors we have enumerated. 

Toynbee's statements, that the Eustachian tube was usually 
a closed canal, that muscular action was required to open it, and 
that swallowing was a simple way of effecting this, led to Polit- 
zer's method of inflating the ear, of the value of which procedure, 
more will be said in our review of the progress in therapeutics. 

Von Troltsch (J 856) began a series of anatomical investiga- 
tions which, we may hope, have not yet ended. His contribu- 
tions relate to the structure of the membrana tympani, the 
muscles of the Eustachian tube, and the pathological anat- 
omy of the middle ear. He described two peculiar constant 
formations on the inner side of the membrana tympani, (pockets) 
which had only been mentioned by Arnold, as folds of mucous 
membrane. In the course of some investigations of the cavity 
of the tympanum of the foetus, he also found that it was filled 
with a proliferation of the mucous membrane of the labyrinth 
wall, which forms a mucous cushion that rapidly lessens in size 
after birth. This anatomical fact, explained the frequency of 
inflammations of the middle ear in young children. 

Gerlach 3 (1858) followed Toynbee in the investigation of the 
fibrous layer of the membrana tympani, and showed that in the 
extreme periphery the circular fibres were wanting. 

Magnus (1880) investigated anew the articulations of the os- 
sicula, and asserted that there was no real joint between the 
malleus and incus. He also denied the voluntary or involuntary 
contraction of the tensor tympani muscle. 

Politzer and Lucse (1862) published the results of experi- 
ments, which were supplementary to those of Muller, showing 
that the origin of a certain crackling sound in the ear was not 
in the tendon of the tensor tympani, but in the Eustachian tube. 



'Lincke: Band I, p. 27. 

2 Diseases of the Ear. English edition. 

5 Sclrvrartze, Archiv fiir Ohrenheilkunde. Bd. I. 



PROGRESS OF OTOLOGY. 13 

Politzer also made valuable experiments upon intra-auricular 
pressure, proving that in the Valsalvian method of inflating 
the ear, not only were the tympanic cavity and the membranes 
of the fenestrse of the labyrinth with the membrana tympani, 
placed under an abnormal pressure, but also the contents of the 
labyrinth— the labyrinthine fluid, the membranous labyrinth, 
and the termination of the acoustic nerve. 

Lucse l showed that a vibrating tuning-fork placed on the 
mastoid process set the membrana tympani and ossicula auditus 
in vibrations which could be represented. 

Corti 2 (1851), an Italian anatomist, reviewed the work of his 
countrymen who studied the cochlea in preceding centuries, 
and divided the lamina spiralis membranacea into two different 
broad zones — an inner one, Zona denticulata ; and an outer, 
Zona pectinata. He described a regular arrangement of pillars 
or rods like the strings of a miniature harp, parts now known as 
Corti's pillars, and for some time supposed to contain the termi- 
nation of the acoustic nerve. 

Kolliker, Claudius, Bottcher, and Deiters, followed Corti in 
investigations of this part, which will be fully noticed in discus- 
sing the anatomy of the internal ear. 

Hyrtl (1858), an anatomist of great industry and reputation, 
made an important discovery of the frequency of a thin and por- 
ous bony covering to the cavity of the tympanum, and thus 
explained how readily, in certain cases, an otitis may become a 
meningitis. 

The pathological anatomy of the ear, which may be said to 
have been first accurately studied by Toynbee, has received large 
additions since his time at the hands of German, English, and 
American writers, among whom are Hinton, Meniere, Voltolini, 
Troltsch and Schwartze. Many contributions upon pathological 
subjects have been made of late to the various otological jour- 
nals. Moos and Steinbrugge, especially have begun to furnish 
accounts of the pathology of the cochlea, which are steps toward 
the clearing up of a dark chapter in aural pathology. 



PROGRESS IN AURAL THERAPEUTICS.— TEXT-BOOKS, DISPENSARIES, AND 

HOSPITALS. 

In the earlier ages, the progress in the treatment of the ear 
by no means kept pace, with the advance in the knowledge of 
its anatomy. While the structure of the organ was sufficiently 



1 Virchow's Archiv. Bd. XXV., Heft 3 and 4. 

2 A Manual of Histology. Strieker, p. 1054 (Translation). 



14 A SKETCH OF THE 

well understood to cause the investigation of its diseases to be 
both interesting and profitable, the treatment was crude and 
illogical, unworthy of the knowledge which should have been 
its basis. 

Herodotus ] says that there were specialists in Egypt, a par- 
ticular physician for each disease, but no mention is made of 
aurists. " The art of medicine is thus divided amongst them: 
each physician applies himself to one disease only, and not 
more. All places abound in physicians ; some physicians are 
for the eyes, others for the head, others for the teeth, others 
for the parts about the belly, and others for internal diseases.'' 

Although Hippocrates knew very little about the anatomy 
of the ear, he speaks at some length of the causes of aural dis- 
ease. For many of these, he must have drawn upon his imag- 
ination. They ivere very comprehensive, and may properly be 
said to explain almost anything. They are such as heat, cold, 
dryness, moisture, the blood, mucus, and the yellow and black 
bile. 

Hippocrates considered internal inflammation of the ear as 
essentially an inflammation of the head. He described pains 
in the ear connected with high fever as a very dangerous dis- 
ease, and he states that if neither pus escaped from the ear, nor 
blood from the nose, the death of the patient usually occurred 
from the ninth to the eleventh day. This was probably the dis- 
ease that we now name acute catarrh of the middle ear, and the 
great medical philosopher was certainly right in calling it a 
serious one. 

Among all the improper remedies which Hippocrates recom- 
mends to be dropped into the ear, there is one good one, although 
it is a very simple application, which is often thought to be a 
suggestion of our own day ; that is, the instillation of warm 
water. The great physician advises the water to be poured in 
by means of a sponge. If this simple, but often efficacious treat- 
ment were universally practised in cases of acute inflammations 
of the outer and middle ear, it would alleviate a great deal of 
suffering. 

Hippocrates seems to have had an eye to the effect upon the 
patient's mind, to use no harsher language, if we may believe 
that the following passage was not, as Lincke insinuates, interpo- 
lated : 2 "If any person has a pain in his ear, the physician should 
roll a bit of wool about his finger, and then pour some warm oil 
into the ear, and then taking the wool in the hollow of his hand, 

1 Herodotus, translated by Gary. Euterpe, p. 125. 
2 Lincke's Handbuch, Bd. H., p. 5. 



PROGRESS OF OTOLOGY. 15 

and hold it before the ear, in order to make the patient believe 
it has come. out of it. In order that the deception may be com- 
plete, the wool should be at once thrown into the fire." 

Hippocrates laid considerable stress upon certain aural symp- 
toms in constitutional disease. For example, he considered the 
presence of sweet ear-wax as a bad symptom, while that of the 
bitter was not. He noted that acute aural disease, sometimes led 
to a fatal result on the third day after its occurrence. This indi- 
cates his perfect appreciation of the serious character of such a 
form of disease. He says that deafness following a fever is 
sometimes cured by nasal hemorrhage or diarrhoea, and so forth. 

Heraclides of Tarent, advises caustics made of verdigris, 
copper filings, and honey, for the removal of granulations aris- 
ing from abscesses in the ear, and for hemorrhages from the 
ear, the juice of white horehound, quince, and gall-nuts mixed 
with vinegar. Galen quotes much from Apollonius in regard to 
remedies for various affections of the ear. A famous remedy 
for earache was burned opium and castoreum. Apollonius rec- 
ommended the oil of bitter almonds for fleas and maggots in 
the ear. He removed foreign bodies by means of ear-spoons, 
little hooks, and probes, which were wound about with wool and 
dipped in turpentine. Hardened cerumen he softened with a 
solution of saltpetre in vinegar, and then cleaned the ear with 
lukewarm water or oil. 

Asclepiades, a friend of Cicero, recommended instillations 
for the ear, of oil in which three or four cockroaches or an 
African snail were cooked, while a piece of henbane in oil of 
roses, or woman's milk, is to be afterward added. 

Aulus Cornelius Celsus (b.c 44-a.d. 19) also used a compo- 
site remedy which was said to be of service in all kinds of dis- 
eases of the ear. It was made of cinnamon, cassia, blossoms of 
bulrushes, castoreum, white pepper, ammonia, myrrh, and saf- 
fron, as well as of various other agents. These substances were 
all rubbed up with vinegar, and diluted with the same agent 
when used. Celsus, in his treatise " De Medicina," spoke in 
some detail of aural disease. He was perhaps the first to recom- 
mend vigorous injections of water in order to remove foreign 
bodies from the ear, although this proper recommendation car- 
ries less weight than it, would have done had it not been mingled 
with a great deal of bad advice, which shows that a disposition 
to use the simplest means for a desired end, is not always con- 
nected with great learning. Celsus recommends in obstinate 
cases of a foreign body in the ear, that the patient should be 
laid upon a table, and upon the side of the affected ear, when 
the surgeon should strike with a hammer upon the table, in 



16 A SKETCH OF THE 

order to dislodge the foreign body by the concussion. Celsus also 
recommends plastic operations for the restoration of lost or dis- 
figured auricles, unless the subjects be unhealthy and cachectic. 

Among the mass of writers mentioned by Lincke, as being 
before Galen's time, Archigenes seems to have had some cor- 
rect notions. He practised venesection for severe pain in the 
ear, and employed purgative enemas, warm baths to the ear, 
especially by means of a sponge dipped in hot water. He warns 
against the use of cold water. He also has his method of re- 
moving a foreign body from the ear, and recommends a vigorous 
shaking of the affected head. A child is to be seized by the 
feet and well shaken, while adults are to be held very much as 
Celsus proposed ; that is, they are to be laid on a table, while 
the leaf of it nearest the head is to be repeatedly opened and 
shut with a slam. Archigenes, like other ancient authorities, 
however, thinks very much of instillations of various kinds for 
the relief of the different forms of deafness. He recommends 
speaking tubes to the deaf. 

Galen (a.d. 130-201) recognized the importance of the ear, in- 
asmuch as it lies so close to the head. Although his classifi- 
cations of disease are very minute, we do not learn much from 
his writings, except the value of agents that will excite the 
secretions of the nose and mouth, which he recommends in aural 
disease. He complains of the empirical practices of his pre- 
decessors, in ordering now cold and now warm remedies, now 
sweet and now sour ones. 

He also tells of a poor patient of some less learned or less 
practical man than himself, who, in accordance with advice, 
used black pepper as a local means of treatment for an inflamed 
ear, and whose sufferings were so much augmented, that he 
came near hanging himself. Galen objects to the too common 
use of opium, which seems to have been employed very much 
in relieving the pain of aural disease. Tinnitus aurium, accord- 
ing to Galen, was due in some cases to exhalations from the 
stomach, and in others to increased sensitiveness of the ears. 
Both of these causes, certainly leave much to be wished for in 
the way of exact knowledge as to the nature of this distressing 
symptom. It would be tedious in the extreme to follow Galen, 
through his classification of diseases of the ear and remedies 
for them. Like his predecessors and contemporaries, he was 
not willing to admit that there were some diseases for which 
remedies were useless, so far as their knowledge went. The 
aural prescriptions of the ancients were usually extremely com- 
posite and correspondingly dangerous. 

Galen makes some very sensible remarks about the various 



PROGRESS OF OTOLOGY. 17 

kinds of sounds that are pleasant or otherwise to the ear. The 
soft and slow tones of the human voice, in his opinion, are much 
the pleasantest to the human ear. A rough and quick voice 
is distressing. Fine ears tolerate only a weak, soft voice, 
diseased ears, only a very gentle and weak tone, sometimes 
even absolute silence. If Galen had lived in the nineteenth 
century, and in New York with its uneven pavements, boiler 
shops, locomotive whistles, elevated railways, and Wagner 
music, he might have added largely to his category of sounds 
unpleasant to tired and morbid ears. Galen's classification was 
a subjective one ; for example : 1, Otalgia ; 2, hardness of hear- 
ing ; 3, cophosis ; 4, paracusis ; 5, paracousmata, or hallucina- 
tions of hearing ; but it was not without value. 

For earache from a cold, he recommends the warming method 
by means of wolf's milk or pepper mixed with old oil. For 
"inflammatory earache" fatty or oily substances are recom- 
mended, the fat of geese and hens ; and if the pain be very 
severe, a mixture of opium, musk, and the white of an egg, with 
or without the addition of castoreum, or a solution of opium in 
thickly cooked juice of fruit. All these substances were poured 
while warm into the ear. 

Dioscorides and Plinius, recommend a host of remedies for 
aural disease. Among others, the latter advises the excrement 
of pigeons and the ashes of horses' dung. 

Cselius Aurelianus, a successor of Galen, stands out promi- 
nently from the absurd theorizers of his time, in his clear de- 
lineations of pain in the ear and his sensible remedies for it — 
leeches, cups, poultices, mustard-plasters, and so on. 

About this time we read of the materia medica of Marcellus, 
who gives us a glimpse of the popular remedies of the day. 
Frog's fat is recommended for pain in the ear ; the urine of 
pigs, of children and men, and the blood of young chickens for 
an ulcer in the ear ; for worms in the organ, the saliva of a 
hungry man, and so forth. We see a great deal in the ancient 
literature, concerning worms in the ear ; so that we must con- 
clude that they were much more commonly found in the olden 
time than with us. This was probabl} r due to the fact that cases 
of neglected suppuration were very frequent, and that living 
larvae were thus often developed. 

The famous surgeon and obstetrician, Paulus ^Egineta (600 
a.d.), who flourished in the seventh century, should be remem- 
bered as a contributor to the surgery of otology. He expended 
much energy on the subject of foreign bodies in the ear. a field 
which has unfortunately always suffered from surgeons over- 
anxious for operations. 
2 



18 A SKETCH OF THE 

Paulus JEgineta made a good classification of cases of closure 
of the external auditory canal : 1, congenital ; 2, from ulcera- 
tion ; 3, superficial or deep. He gives sound advice as to the 
removal of aural polypi, divides deafness into congenital and ac- 
quired, and seems altogether to have been a man in advance of 
his time. His surgical writings are said to abound in novel and 
ingenious views. He suggested the operation of detachment of 
the auricle for the removal of foreign bodies situated in the 
tympanic cavity or deep in the external auditory canal. This 
operation was again advised by Troltsch and was performed 
(1871) by the author of this volume, and by Orne Green (1881), 
and Buck (1882), and in spite of theoretical objections urged 
against it, has proved itself a practical operation in certain cases. 
Hippocrates, also, is said to have recommended this procedure. 

Guido Guidi ( 1595) about this time, in his recapitulation of the 
works of Hippocrates, Celsus, Galen, Paul of JEgina, and others, 
gives the sensible advice to keep the ear uncovered, and the 
meatus unstopped, in order, as he says, that sound may enter it 
properly and the ear-wax run out freely. For congestion of the 
ear, he advises leeches placed in the nostrils. 

According to Lincke, the Arabians got their knowledge of 
otology, whatever it was, from the Greeks, of whom Galen was 
the chief authority ; so that we can only add a few more absurd 
remedies as their contribution to knowledge : for deafness, the 
brain of a lion mixed with oil (the brain, not the lion) is advised 
by Rhazes. Serapion advises instillation of woman's milk, for 
the cure of earache in children, and he gives the important 
caution, that the milk must be that of a woman who is nursing 
a female infant, if it be a boy, who is affected. 

As we have seen in noticing the progress in our knowledge 
of the anatomy of the ear, the centuries from Galen to Valsalva 
were dark ages for our science. Lincke says : " Otology re- 
mained at the same point at which the Grecian, Roman, and 
Arabian physicians had left it." In Lincke's own list of the 
progress of these centuries we find traces of ignorance and em- 
piricism only. One author named Gadesden recommends that, 
in cases of inflammation of the ear, one of the lower classes be 
hired to suck out all the morbid material of the ear, by means 
of a tube placed in the meatus externus ; and this is said to be 
a cure for all kinds of deafness, not even excepting that from 
a purulent affection of the organ. Lincke believes that Peter de 
la Cerlata was the first to use a speculum for widening the audi- 
tory canal for purposes of inspection. 1 

1 The passage quoted to sustain this view is "per inspectionem ad solem trahendo 
aurem et ampliando cum speculo aut alio instrumento." 



PROGRESS OF OTOLOGY. 10 

Johannes Arcularius (15G0) gave some sensible rules for the 
management of aural disease. He declaimed, for instance, 
against the indiscriminate practice of stuffing the ear with cot- 
ton ; but he advised an extremely peculiar means of extracting 
a foreign body from the ear. The head of a lizard is to be 
cut off, placed in the affected ear, and allowed to remain there 
for three hours. The animal is then to be removed, when the 
foreign body will be found in its mouth. 

Alexander Benedetti (1560) recommends, as a remedy for 
pain in the ear, the semen of a boar, which is to be carefully 
taken from the vagina of a sow before she has dropped it upon 
the ground. This, however, is the suggestion of a writer on 
general medicine, and not on otology. 

Gabriel Fallopius (1543-1562), professor of anatomy, surgery, 
and botany in Ferrara and Padua in this century, seems to be 
entitled to the honor of having first taught that a discharge of 
pus from the ear of a child should not be meddled with ; for 
as Fallopius gravely taught, and as was gravely repeated by 
some of his legitimate successors for more than three hundred 
years, this discharge of pus is an effort of nature to throw 
morbid material out of the head through the ear. The otorrhcea 
of adults, according to Fallopius, is also a discharge from the 
brain, and should not be treated by astringents, but with mild, 
cleansing remedies. He used an aural speculum, and employed 
sulphuric acid to remove polypi. 

The great revolutionist in medicine, Paracelsus (1490-1544), 
who began his lectures at Basle, by burning the books of his 
predecessors, and who afterward boasted of having read no 
books for ten years, seems to have paid very little attention to 
the treatment of diseases of the ear. Deafness he considered to 
be incurable, "for what nature had once taken away a physi- 
cian could by no means restore." He had, however, like all the 
ancients, his remedy for worms in the ear, and one for each kind 
of worm. 

In the latter half of the sixteenth century, a certain Capivacci 
seems to have deviated a little from the errors of his predeces- 
sors. He speaks with more precision of aural disease. He de- 
scribes thickening, ulcers, and cicatrices of the membrana tym- 
pani, and says that deafness which arises from an affection of 
the nerve or labyrinth is incurable — a declaration which his 
successors, three hundred years after him, find true of a large 
proportion of cases. Capivacci also describes a method of mak- 
ing a differential diagnosis between the diseases of the per- 
ipheric, and of the central parts of the organ of hearing. One 
end of an iron rod, an ell in length, is put between the teeth of 



20 A SKETCH OF THE 

the patient, while the other is placed upon a keyed musical in- 
strument, such as a zither. If he could distinguish the tones 
produced by the vibrations of the keys of the instrument, his 
deafness depended upon some lesion of the membrana tympani ; 
if not, it was an affection of the nerve. Here we see glimpses 
of deduction from the anatomical knowledge of the time. 

In the seventeenth century, we hear of De Vigo (1600), body- 
surgeon to Pope Julius II., curing his Holiness of a very obsti- 
nate abscess of the right ear by means of a mixture, or lini- 
ment, of 3 ij. of oil of eggs with 3 iij. of oil of roses. What kind 
of an abscess this was, or where it was situated, Lincke does 
not tell us. De Vigo was opposed to the removal of foreign 
bodies by means of the detachment of the auricle, because this 
part was too sensitive for an operation, and quia natura sagax 
raro vel nunquam deficit in orsis bonis operationibus. 

Peter Forest, who may have been an Englishman, judging 
from his name, but who practised in Rome in this century, to 
whose works Lincke gives no definite reference, collected fifteen 
cases of aural disease that seem to have been carefully observed. 
One is a case of disease of the ear, ending in an affection of the 
brain and death. He speaks of pain in the ear caused by the 
rays of the sun, and he tells a wonderful story of a female deaf 
for seven years — so deaf that she could not hear a clock strike — 
who, being advised by that character so common in medical 
scenes, an old woman, to put some musk in her ear, did so, and 
was cured. He also tells how his teacher, Gisbert Horst, the di- 
rector of a hospital in Rome, used to cure deafness with water 
that had been distilled over a young mouse having no hair. 

We trace one of the delusions that still lingers among us — 
namely, that the hearing is completely destroyed when the 
membrana tympani is broken — to a writer named Hercules Sas- 
sonia, who lived in this century. He also had the peculiar no- 
tion that patients always spoke in a low tone when the disease 
of the ear was seated in the auditory nerve, because the nerve 
supplying the tongue, a branch of the fifth, was at the same time 
affected. In deafness arising from venereal disease, blisters 
behind the ear and a mixture of oil of guaiacum and hydro- 
chloric acid as a local application, of which the patient drank a 
little, were highly spoken of. 

The great Frenchman, the father of modern surgery, Am- 
broise Pare (1510-1590), figures in otological history as the first 
one to employ a syringe for cleansing the ear. He also recom- 
mended artificial auricles of papier mache or leather. 

It was in the latter half of the sixteenth century, that zeal 
for the education of deaf mutes first began to exhibit itself. It 



PROGRESS OF OTOLOGY. 21 

is probable that the Greeks and Romans made no efforts in this 
direction, for they had decided that nothing reached the intel- 
lect except through the hearing, that there could be no intel- 
lectual process without hearing, and they had given over deaf 
mutes as they did idiots and insane people. Although isolated 
instances had been noted of instruction for the deaf mute — in- 
stances like that of the dumb youth taught by one of the early 
English bishops, St. John of Beverley — they were generally con- 
sidered as supernatural occurrences. Rodolphus Agricola, of 
Groningen, born in 1442, stated that he knew of a deaf mute 
who had been taught to write and note down his thoughts. 
Fifty years afterward this was denied, on the ground that no one 
could be instructed who could not be taught through the ear. 

Jerome Cardan, who was born in Pavia in 1501, is said to be 
the man who showed that written characters and ideas may be 
connected together without the use of sounds. This fact, now 
universally accepted and assumed, was a new idea in the six- 
teenth century. Benedictine monks in Spain, first put Cardan's 
principles into practice, and from that country they gradually 
spread throughout the civilized world, until now in every nation 
the deaf mute, like his more fortunate fellows, has an oppor- 
tunity for education. The reader has seen what a great debt the 
scientific world owes to Italy, and nowhere is this more apparent 
that in what was promulgated by Cardan. 1 

Caspar Tagliacottzi (1597), of Bologna, who did so much for 
plastic surgery, did not neglect the ear, but attempted to restore 
the auricle by taking integument from the adjacent skin. He 
relates one case, that of a Benedictine monk, for which he had 
done this with success. 

Although the aural speculum had been used a hundred years 
before, we find a certain Johann Hartman (1690), a disciple of 
Paracelsus, very unwilling to use it ; for he advised the detec- 
tion of inspissated cerumen by the following simple method. 
He placed a curved silver tube into the ear and blew through it. 
If the patient felt the breath to be cold, the deafness did not 
proceed from impaction of wax. In our day the detail of this 
method is sometimes simplified without altering the principle ; 
that is to say, a probe is used to see if wax is in the ear. Through 
all this century, the seventeenth, there are numerous volumes 
on the treatment of the ear, but they all tread through the bar- 
ren waste of drops and decoctions, theories, nomenclatures, and 
rank empiricism. 

Lusitanus gives an amusing explanation of the practice of 



1 Encyclopedia Britannioa, Vol. VII. Article, Deaf and Dumb 



22 A SKETCH OF THE 

cutting off the ears of thieves. He said that such treatment 
rendered them incapable of propagating their kind, and hence no 
more thieves could be born of them. He founded this opinion 
on the statement of Hippocrates that the division of the veins 
behind the ear, rendered a man sterile, because the semen, which 
was generated in the head, could no longer pass down to the 
genitals. 

Johann Baptista van Helmont, evidently a Belgian, casts 
away the theory that had so long prevailed, of deafness being- 
caused by ascending exhalations, and clears up the whole matter 
by ascribing it to the work of the devil, or other evil spirits. 

Marcus Banze (1640) gives us the first idea of an artificial 
membrana tympani, by proposing to place a tube of ivory, the 
end of which is covered by a bit of pig's bladder, in the auditory 
canal, as a protection to the exposed ear, when the membrana 
tympani was lost by ulceration. He did not, however, propose 
this as an improvement to the hearing power. 

The renowned surgeon, Fabricius of Hilden (1646), or Fabri- 
cius Hildanus, so called to distinguish him from Fabricius of 
Acquapendente, contributed somewhat to the surgery of the ear. 
He invented an instrument for extracting foreign bodies from 
the ear, as, indeed, every surgeon of eminence seems to have 
thought it his duty to do. This instrument consisted of a large 
tube which was introduced into the auditory canal down to the 
foreign body ; of a smaller tube with a toothed extremity placed 
inside of this, and in this again a trephine, which was turned 
in an opposite direction from the second tube containing the 
teeth. He also wrote of the removal of aural polypi. 

In the latter half of the seventeenth century, Thomas Willis ' 
attempted to prove, by experiments on animals, that total deaf- 
ness does not ensue when the membrana tympani is destroyed. 
He also made some interesting observations on deaf persons 
who only heard in the midst of a noise. The most interesting 
one is that of a woman who could only hear her husband when 
a servant was beating a drum. The conversations in that 
family were probably not very protracted. This kind of im- 
pairment of hearing, which was called paracusis Willisiana, 
was referred by its describer to a relaxation of the membrana 
tympani, the normal tension being restored by the noise, or 
vibrations of the atmosphere. These observations will be found 
in full in the latter part of this book. 

Du Verney (1683), known by his labors in the anatomy of the 

1 Opera Omnia Amstersedarnia apud Henricum. Wetsteiilum. Fars physiologica. 
Cap. xiv., p. 67. 



PROGRESS OF OTOLOGY. 23 

ear, and his work on its diseases, contributed very little to sound 
knowledge, although he made an attempt to arrange the dis- 
eases in accordance with the anatomy. He however, disputed 
the generally accepted opinion that a discharge of pus from the 
ear came from the brain, and showed that the meatus audi- 
torius internus was closed by the auditory nerve, and that the 
pus must pass through the cochlea and the fenestra ovalis and 
fenestra rotunda, before it could get into the external auditory 
canal. 

Du Yerney modified the suggestion of Hippocrates to get at a 
foreign body not otherwise easily removed, by making an open- 
ing behind the ear, and recommended tha/fc the incision be made 
upon the upper side, because the vessels are smaller in this po- 
sition. He thus anticipates Von Troltsch, who made the same 
modification of the original suggestion nearly two hundred 
years later. 1 

In the works upon the ear that appear in this century, we still 
continue to hear much of the presence of worms, or living lar- 
vae — a state of things, however common among the ancients, 
that is now very rare, because suppurating ears are usually 
cleansed. The disgusting and magical ear-drops of the early 
and dark ages are still used in this latter part of the seventeenth 
century. Thus one writer records, that a Capuchin monk mixed 
the urine of a female donkey, that had brought forth but once, 
with that of a male hare, of a wolf, or in case of the absence 
of the latter, of an entirely white goat, warmed it, and adding a 
little oil of caraway, used it as drops for the ear. Urine of the 
various animals figures largely among the ear-drops of the pe- 
riod. Paullini, one of the writers of the day, is in doubt, how- 
ever, whether it is proper that women should use the renal 
secretion of dogs as a remedy for deafness. 

We begin to hear more in the latter part of the seventeenth 
century of the education of the deaf and dumb, but it is mingled 
with much that is absurd in attempts at treatment. The great 
error was then made, as it often is now, of supposing that the 
diseases of the ear which produced deaf-muteism, were of a dif- 
ferent nature from those which in the adult cause deafness only. 

John Wallis, an Englishman, was perhaps the first to in- 
struct a deaf-mute to, speak — and he instructed him so that he 
spoke very well. The case was one of acquired deaf-muteism, 
the patient having lost his hearing at eight years of age ; but 
he became able to read the Bible aloud, and to converse with 
some fluency. 

1 Diseases of the Eur. English translation, p. 488. 



24 A SKETCH OF THE 

Lincke begins his account of the progress of otology in the 
eighteenth century, with the lament that it did not keep pace 
with the anatomical investigations of the ear, which had been 
brought to such a high point by the labors of Valsalva, Casse- 
bohm, Cotugno, and Scarpa, and he says that otology would 
have advanced very much faster, had Antoine Marie Valsalva 
devoted himself more to its prosecution. But Valsalva did 
much to give us correct notions in regard to the diseases of the 
ear. He proved that there were cases where the membrana 
tympani had been restored. He showed that the hearing power 
is merely impaired, not lost, by a perforation of the membrana 
tympani. He recognized anchylosis of the base of the stapes as 
a cause of deafness. He gave us the Valsalvian experiment — 
the mode of forcing air through the Eustachian tube by a forced 
expiration, with the mouth and nostrils closed — and he advises it 
as the best means of cleansing the middle ear from pus. He 
proved that the cavity of the tympanum is connected to the cells 
of the mastoid process, by a case in which he injected the former 
through a fistulous opening in the latter. 1 He also showed that 
closure of the Eustachian tube is often a cause of impairment 
of hearing. This is certainly a refreshing catalogue after we 
have been wading through the disgusting empiricism of the 
centuries before. 

He reports the case of a man who suffered from a nasal poly- 
pus, which gradually by its growth closed the pharyngeal orifice 
of the Eustachian tube, and caused deafness. He also relates 
the case of a man, who suddenly lost his hearing while suffering 
from a pharyngeal ulcer in the neighborhood of the tube, when 
a tent was placed in the ulcer, but who immediately regained it 
when the tent was removed. Valsalva's century is, however, 
also cursed with theoretic treatises on aural disease, such as 
that of one Frederich Hoffmann, who goes on, in the good old 
way, with instillations of wonderfully compounded ear-drops. 
Lincke mentions numerous inaugural dissertations of this time, 
but they relate chiefly to cases that were not properly understood 
by the reporters of them ; and these authors, as well as their 
theses, are deservedly forgotten. 

J. L. Petit (1774), in a work upon surgical diseases, reports 
many interesting cases of caries of the temporal bone. In one 
case of suppuration in the ear, with caries of the mastoid, he ad- 
vised that this part should be cut down upon and trepanned. 



1 As I have elsewhere shown, this case was for a long time supposed to be one of 
perforation of the mastoid by a surgical operation. See chapter on the diseases of the 
mastoid. 



PROGRESS OF OTOLOGY. 25 

His advice was not followed, and the patient died. He also re- 
lates cases where this operation was successfully performed, 
and he must therefore be considered as the originator of this 
valuable means of treatment. 1 

We then come to the famous postmaster of Versailles, Guyot 
(1724), who first injected the Eustachian tube. His own hearing 
was impaired, and in order to relieve it he introduced an angu- 
lar tube of tin through the mouth, opposite (gegeri), not into, the 
Eustachian tube. The distal extremity of this instrument was 
attached to a leathern tube. This was connected to the reser- 
voir of two small pumps, which were moved by two cranks and 
a wheel fastened in machinery, by means of which he forced 
fluid through a curved pewter tube, placed behind the uvula, 
into, or about, the mouth of his Eustachian tube, and relieved 
the impairment of hearing. 

Beck 2 (1735), who quotes from the "Hist, de l'Acad. des 
Sciences," thinks that Guyot washed out the mouth of the Eusta- 
chian tube. We now know, that even this is a very valuable 
means of treatment. I regret very much that I cannot find 
Guyot's original report to the French Academy, in any of our 
New York libraries. 

Archibald Cleland (1711), an English army surgeon, advised 
injections of the Eustachian tube with warm water, by means of 
a syringe joined to a flexible silver tube introduced through the 
nose into the oval opening of the duct, at the posterior opening of 
the nares, toward the arch of the palate. A sheep's ureter was 
fastened to the silver tube, to the other end of which the syringe 
was fastened. His contemporaries seem to have paid little 
attention to his suggestions, for Van Swieten recommends 
catheterization of the tubes through the mouth as a possible 
operation. Wilde attempts to claim the use of the catheter as a 
British discovery. He makes Guyot a mere suggester of the 
operation of catheterization, but I think the evidence is in favor 
of the French postmaster. Cleland also used probes of the same 
size of the catheter to explore the tube. He does not allude to 
Guyot's suggestions to the French Academy, but, unfortunately 
for poor human nature, this is by no means proof that he did not 
know of them. Certain it is, however, as Wilde states, that the 
English surgeon was the first one to introduce the catheter 
through the nose, the only proper way of performing the opera- 
tion ; and he says that Guyot never practised the operation 



1 For a full account of the operations on the mastoid, see the appropriate chapter 
in this work. 

2 Die Krankheiten des Gehoerorganee, 1827, p. 21. 



26 A SKETCH OF THE 

which he recommended, and that it was on this ground rejected 
by the French Academy, as "he wanted the recommendation of 
facts to support and enforce it." 

Archibald Cleland still farther advanced the science of otol- 
ogy by introducing a three-inch convex lens, with a handle, as 
a means of examining the ear. The ear was illuminated by a 
waxlight attached to the lens. 

Julian Busson (1748) proposed, in rather an undecided way, 
to perforate the membrana tympani, in order to remove collec- 
tions of pus from behind it ; but, as this was a very dangerous 
operation, he advised the inhalation of vapors through the 
mouth and nose, and then that they be forced into the Eusta- 
chian tube by means of Valsalva's method, as he thought that 
the pus might thus be driven out of the middle ear. 

Jonathan Wathan (1755), an English author, reported cases 
of restoration of hearing by means of catheterization of the 
tube through the nose. His paper is in the " Philosophical Trans- 
actions of the Royal Society." He seems not to have known of 
Cleland's labors in the same direction. 

The surgeons, after the seemingly complete failure of phy- 
sicians to successfully treat diseases of the ear, animated by the 
invention of the Eustachian catheter and Petit's operation for 
perforation of the mastoid, seem to have been exceedingly ac- 
tive in otology during the latter half of the eighteenth century. 
Antoine Petit, as well as Cleland, recommended the use of an 
instrument through the nose instead of through the mouth, as 
proposed by Guyot, and injections through the tube are every- 
where recommended, in their writings. 

The successful cases which were reported about this time 
were usually among young persons. It is probable that the use 
of the Eustachian catheter fell into disrepute, because it was 
used in chronic cases in which the prognosis should have been 
pronounced bad or hopeless from the beginning. The want of 
success in such cases must have been disheartening. It con- 
tributed much to the opprobrium attached to the practice of 
aural surgery, which exists in our own day. The necessity for 
greater exactness in the diagnosis and course of disease, exists 
now as then. If we achieve it, otology will be on as sure a foun- 
dation as any part of our science and art. 

One very careful soul, who seems to have been in great horror 
of the operation, proposed that patients upon whom the catheter 
was to be used, should have the hairs of the nostrils removed, 
and that lukewarm milk, or a linseed-meal mixture, or the like, 
should be drawn into the nostrils a day before the instrument 
was introduced, so as to make the parts more pliable. 



PROGRESS OF OTOLOGY. 27 

The operation of perforation or trephining the mastoid process 
also fell into great disrepute, because a Danish surgeon, Berger 
(1792), caused it to be performed upon himself, and very im- 
properly, for " deafness which had been years in occurring, and 
which was accompanied by vertigo, headache, and noise in both 
ears." Meningitis resulted, and the patient died in a few days. 
This put a stop to the performance of this very useful and neces- 
sary operation, until it was lately revived, chiefly through the 
efforts of German and American surgeons. 

Everard Home J (1800), by his writings, suggested to Sir Ast- 
ley Cooper the operation of perforation of the membrana tym- 
pani, which the great English surgeon performed successfully 
in four cases. The history of the rise and fall and revival, of 
this operation will be found in the chapter on chronic non-sup- 
puration of the middle ear. 

John Cunningham Saunders 2 wrote a work on the ear, its 
anatomy and diseases, which went through several editions in 
England and one in America. It is a brief but scientific trea- 
tise, and far beyond its predecessors in value. It is character- 
ized by simplicity, and is without the absurdities of the older 
text-books. It is deficient in descriptions of the methods of 
examining the drum-head, and teaches the erroneous doctrine 
that it is proper to probe a membrana tympani to see if it be in- 
tact. It should be remembered that Saunders advised paracen- 
tesis of the membrana tympani in cases of acute suppuration of 
the tympanum — an operation that was revived by Schwartze a 
few. years ago. 

He says 3 : "But let it be admitted that the tympanum has 
suppurated, ought the membrana tympani to be abandoned to a 
casual ulceration, or is it better to open it by art ? I am inclined 
to prefer the latter, and if I can be assured, by any symptom, 
that suppuration has taken place, I should not hesitate to make 
a small perforation of the membrana tympani, and to repeat it, 
if necessary, taking, at the same time, every precaution to sup- 
press the fresh collection of matter." 

Saunders speaks wisely against the objections made to check- 
ing a purulent discharge from the ears, and shows that disease 
of the brain is very apt to follow a neglected chronic suppura- 
tion, and he gives some interesting illustrative cases. The book 
is very deficient in its treatment of the Eustachian tube and 
middle ear. Thus early do we find, in spite of Cleland's and 

1 Philosophical Transactions, 1800. 

2 The Anatomy of the Human Ear, etc. Edited by Win. Price, M.D., Philadel- 
phia, 1827. 

3 Loc. cit., p. 59. 



28 A SKETCH OF THE 

Wathan's teachings, the English prejudice against the use of 
the catheter, a prejudice which has only lately been overcome. 

Saunders was the first to establish an infirmary for the treat- 
ment of diseases of the ear. It was also an eye infirmary, and 
was opened in March, 1805. At a later date it was limited to 
the treatment of the diseases of the eye. In 1816 John Harrison 
Curtis established the " Koyal Dispensary for Diseases of the 
Ear," in London. The work of Curtis ' adds nothing to our 
knowledge, being a feeble imitation of the book by Saunders. 

J. A. Saissy (1819), of Lyons, devoted the last twelve years 
of his life to the study of aural disease. He published a work 
on the ear, which attained the honor of a place in the " Diction- 
naire des Sciences Medicales." This work was translated into 
English by Nathan R. Smith, the celebrated American surgeon. 2 

I. M. G. Itard (1821), Physician to the Royal Deaf and Dumb 
Institution in Paris, also publishes a treatise, which was trans- 
lated into German, 3 and which did much in the pioneer work of 
clearing up the undergrowth of centuries of neglect. 

Then followed Deleau, on the diseases of the middle ear and 
on perforation of the membrana tympani, an operation for which 
he claimed more than it deserved. 

Thomas Buchanan (1823), of Hull, published a work on the 
ear, which is highly spoken of by Sir William Wilde, especially 
as to his remarks upon catheterization of the Eustachian tube 
and puncturing the membrana tympani. He had, however, fal- 
lacious views with regard to the physiology and diseases of the 
external auditory canal. 

Karl Joseph Beck (1827), of Freiburg, published a ''Handbook 
of the Diseases of the Ear." 4 It is a succinct and carefully writ- 
ten compendium of what was then known in this department of 
science, and has a very good bibliography, with the exception 
that the names of English authors are very often misspelled. 

Wilhelm Kramer (1833), of Berlin, an author who died in 1874 
at a ripe old age, brought out a work which was animated by the 
true scientific spirit, and which greatly simplified the practice 
of otology. After this he published a number of volumes. He 
introduced a valvular-handled speculum, that was an improve- 
ment upon the very clumsy ones hitherto in use. He also gave 
us the air-press, by which air or vapors could be introduced 
through the Eustachian tube into the middle ear. 

1 A Treatise on the Physiology and Diseases of the Ear, by John Harrison Curtis, 
Esq. Third edition. London, 1823. 

2 An Essay on the Diseases of the Internal Ear. Baltimore, 1829. 

3 Die Krankheiten des Ohres und des Gehors. 

4 Die Krankheiten des Gehoerorganes. Heidelberg und Leipzig, 1827. 



PROGRESS OF OTOLOGY. 29 

In discussing the practices of his predecessors, the intoler- 
ance of Kramer's spirit is seen — an intolerance which is pain- 
fully manifest in his later works. 1 In 1860 he speaks of the 
writing's of Hinton of London — a writer whom, I am sure, all 
my readers will learn to respect — " as in every respect unimpor- 
tant," while Toynbee's pathological investigations, to which 
science is so much indebted, are actually treated with sneers. 
In 1865, Kramer published a monograph, 2 which was essentially 
a review in a very unfriendly spirit of the labors of Toynbee, 
Wilde, Troltsch, Erhard, Voltolini, and others, of whose writ- 
ings I shall soon speak. What good work Dr. Kramer actually 
did for otology in his younger days, was overshadowed by his 
subsequent writings. In spite of what I am almost inclined to 
call common sense, he persisted in rejecting the modern method 
of investigation, as well as the results of examinations of ears 
removed from persons who have been deaf. He still continued 
to use the handled bi-valved speculum, with sunlight as the 
only source of illumination, and on cloudy days sent away 
patients without examination up to his last days of practice; 
and because Toynbee made post-mortem examinations of many 
ears of persons whom he had not seen during life, Kramer re- 
jected all pathological investigations, except experiments con- 
ducted upon a dead body or a glass model. He described Politzer's 
method of inflating the middle ear "as a miserable resort in 
cases of necessity, the employment of which, all pompous com- 
mendations to the contrary notwithstanding, stamps him who 
uses it with want of skill in the introduction of the catheter." 
Again he called Toynbee, in his work published in 1867, 3 and this 
after Toynbee had lost his life in experiments as to the effect of 
chloroform and hydrocyanic acid, "a wretched aural surgeon." 
"Ein miserabler Ohren-arzt." These are fair specimens of Dr. 
Kramer's style in dealing with an opponent, with any one who 
claims to have accomplished anything for aural pathology and 
therapeutics in any other way than by the employment of his 
catheters, his bougies, and his valvular-handled speculum. 

Yet Kramer did much for the advance of otological science. 
If he had possessed an unprejudiced and receptive spirit, he 
would have accomplished much more. The author well remem- 
bers him in his pleasant consulting room in Berlin, in 1862, dis- 
dainfully declining to use the simple method of examination just 
recommended by Troltsch, but sending away his patients who 



1 Ohrenheilkunde der Gegenwart, 1800. Berlin, 18(>1. 

2 Olirenkrankheiten and Ohrenartze in England and Deutsohland. 

3 Handbuoh dor Ohrenheilkiin.de, p. 44. Berlin, 18(37. 



30 A SKETCH OF THE 

needed examinations on dark days, to wait until the sun should 
shine. He frequently visited England, and had quite a large 
consultation practice there. He unwittingly did much to deepen 
the general distrust of the treatment of aural disease. 

In this review of what has been done to bring otology up to 
its present position, I have been compelled to notice the difficul- 
ties with which the advance of the science has been obliged to 
contend in the way of improper and unjust criticism, from one 
who, in this country and England, acquired the reputation of 
a safe guide and leader in this part of the field of medicine. 

Joseph Williams 1 (1839) obtained a gold medal from the Uni- 
versity of Edinburgh for a monograph upon the anatomy, phys- 
iology, and pathology of the ear. It is an excellent compilation 
of the knowledge of his time, written in a pleasant style, ap- 
parently by a writer with very little or no experience of his 
own. 

George Pilcher (1841) wrote an essay on the ear, which re- 
ceived the Fothergillian gold medal from the Medical Society of 
London. It is a valuable compilation. The section on foreign 
bodies in the auditory canal is full of warning interest. There 
is, however, very little of the author's own experience in the 
volume. 2 

The text-book of Wilhelm Rau 3 is written in an attractive style 
and scientific spirit, but unfortunately for its permanent hold 
upon the profession, it does not anticipate the real advance so 
soon to be made by Troltsch in giving us a simple method of ex- 
amining the drum-head, the stand-point for modern otology, 
just as much as Sims's speculum is for gynaecology, and it has a 
place among books written from the knowledge of the ancients. 

The work of James Yearsley, 4 although having some unscien- 
tific characteristics, as its title would indicate, is a valuable 
book, especially for its sound doctrine with regard to the origin 
of most cases of impaired hearing in the mucous membrane 
lining the throat, nose, and ear, and for its account of the dis- 
covery of the artificial membrana tympani. 

The profession has of late become more alive to the value 
of Yearsley's artificial drum-head, which, as is well known, is 
formed of cotton, by the papers of American, German, and Eng- 
lish otologists, but nothing essentially new has been added to 
the original statements of its inventor. The history of the man- 

1 Treatise on the Ear. London : Churchill, 1840. 

2 Treatise on the Structure, Economy, and Diseases of the Ear. American edition, 
1843. 

3 Lehrbuch der Ohrenheilkunde. Berlin, 1856. 

4 Deafness, Practically Illustrated. Sixth edition. London, 1863. 



PROGRESS OF OTOLOGY. 31 

ner in which the value of an artificial membrana tympani was 
suggested to Yearsley is interesting. 

In 1841 a gentleman from New York consulted Dr. Years- 
ley, in London, in regard to his deafness, who informed Dr. 
Y. that he was enabled to improve his hearing power so 
that he could produce in his left ear a degree of hearing quite 
sufficient for all ordinary purposes. This was done by the in- 
troduction " of a spill of paper previously moistened with cotton 
to the bottom of the passage upon the remains of the membrana 
tympani." ' 

This was the real discovery of the artificial membrana tym- 
pani, although Dr. Martel Frank, in his cyclopaedic text-book, 
refers to a means of preventing injury to the ear, but not of im- 
proving the hearing when the membrana tympani is lost, by 
the use of a silver, gold, or lead tube, the inner end of which 
is covered by a membrane. The fact that such a means of pro- 
tecting the ear was used in 1640 has been already alluded to. 
It cannot be said, however, to be an artificial membrana tym- 
pani in the sense of Yearsley's cotton-wool, which he soon sub- 
stituted for the paper of the New York patient, or of Toynbee's 
disk of rubber attached to a wire. The artificial membrana 
tympani has proved itself a very valuable means of treatment, 
and is in constant use by many of those who treat suppurations 
of the middle ear. 2 Of late years, the use of the artificial drum- 
head has assumed great importance in the minds of the laity, by 
its recommendation for all diseases of the ear, by interested ad- 
vertisers, who describe it as a new invention, and sell it for a 
very large price. 

The work of Dr. Frank, 8 already alluded to, will be found a 
valuable work of reference, although it lacks individuality. 
Hoffman's mode of examining the auditory canal and mem- 
brana tympani is fully described by Frank on page 10 of his 
book ; but he attached no importance to it, not foreseeing 
that it was to supersede all other methods, as it has done, as im- 
proved and brought into general use by Von Troltsch. 

The work of William R. Wilde 4 (18.43), surgeon to St. Mark's 
Hospital, which was republished in this country, where it has 
had a large circulation, and which was translated into German, 
probably did more to place our science upon a sound basis, than 
anything that has been done in otology since the days of Yal- 

1 Loc. cit, p. 221. 

2 Frank, p. 29;}. 

3 Praotische Anleitung zur Brkenntniss und Behandlung der Ohrenkrankheiten, 

Erlanger, 1845. 

4 Practical Observations on Aural Surgery. London, 1858* 



32 A SKETCH OE THE 

salva. This work was founded on the observations of a careful 
observer, who had acquired fine habits of study as a skilful 
ophthalmologist. It was not, as the works of Lincke and Frank, 
a cyclopaedia of what had been written on otology, nor did it 
contain absurd theories like that of Kramer, but it consisted 
in the application of thorough anatomical, physiological, and 
therapeutical knowledge to the study of an organ that had 
been hitherto treated as if it were something different from 
any other part of the body, and not subject to the same ac- 
cidents and diseases, and consequences of those diseases, as 
other parts made up, in like manner, of integument, of carti- 
lage, mucous membrane, periosteum, and bone. In fact, Wilde 
— afterward Sir William Wilde, in consequence of the well- 
earned recognition of his Queen — brought otology, or aural sur- 
gery as he called this department, down from the terra incog- 
nita of the ancients to a point where it could be investigated by 
the average practitioner, and where it was respected by all. He 
gave us the conical specula, reviving a suggestion of Dr. New- 
burg, of Brussels, and Ignaz Gruber, of Vienna, and drove the 
unhandy ones of Fabricius and Kramer out of use. More than 
all, he taught us that the true nature of aural disease was in- 
flammatory in a large proportion of cases. With this as a stand- 
point, he inaugurated a successful system of antiphlogistic 
treatment by means of incisions in tense tissue, local blood-let- 
ting, blisters, the administration of mercury, and so forth. This 
system, although modified and enlarged, still obtains with our 
wisest practitioners, and is an everlasting monument to the 
genius of its promulgator. He displaced the fanciful and theo- 
retical notions of Kramer, which were having wide credence, to 
the great detriment of the scientific knowledge of the nature 
and treatment of diseases of the ear. He was the first author 
to place aural surgery upon a rational basis. Wilde deserves 
the title of the Father of Modern Otology. 

Then came Toynbee's book * (1860), which is mainly valuable 
for its anatomical and pathological investigations. It can never 
take rank with Wilde's book as a useful treatise for the practi- 
tioner, indispensable as were Toynbee's labors as an anatomist 
and pathologist. Mr. James Hinton's supplement, however, 
materially improved Toynbee's treatise. 

Dr. Anton von Troltsch (1861 ), of Wiirzburg, published a mono- 
graph 2 upon the anatomy of the ear, in 1861, which he entitled 

1 The Diseases of the Ear : their Nature, Diagnosis, and Treatment. Eeprint. 
Philadelphia, 1860. The same, with a supplement, by James Hinton, F.R.S. Lon- 
don, 1868. 

2 Die Anatomie des Ohres. Wiirzburg, 1861. 



PROGRESS OF OTOLOGY. 33 

a contribution to the scientific establishment of otology. It was 
certainly all that and something more. "While it gave a very 
simple and complete account of the anatomy, except that of the 
internal ear, there were many wise suggestions in the text 
with regard to the treatment of aural disease. Troltsch showed 
himself to be a disciple of Wilde and Toynbee. He built upon 
the foundations which the clinical skill of the Irish, and the 
pathological labors of the English observer had made, and 
brought otology in Germany into a position which made it an 
inviting department of labor. His work upon the anatomy con- 
tains the results of many original investigations, which will be 
found in the anatomical descriptions of this volume. 

This work on the anatomy of the ear was soon followed by a 
text-book upon its diseases, 1 which had the same scientific char- 
acteristics with the monograph upon the anatomy. It has been 
translated into the English, French, and Italian languages. In 
this country it met with great favor, having passed through two 
editions, and it has given tone to all the otological literature and 
investigations of its day. Troltsch improved and brought into 
general use the method of examination of the canal and drum- 
head first proposed by Dr. Hoffman, of Westphalia — which had 
been entirely forgotten by the profession — and thus at one step 
advanced the science very materially. 

In 1862, the same year that Von Troltsch issued his text-book, 
Dr. Adam Politzer, of Vienna, promulgated his method of inject- 
ing air into the middle ear, the so-called inflation. It is hard 
to overestimate the value of this simple procedure, and the 
benefit to our science and art that its invention caused. The 
writer can but quote the opinion of an eminent practitioner of 
this city, of large experience in aural disease, who, in speaking 
of Politzer s method, once said to him : "If a man were to take 
this air-bag and travel through the country, advertising himself 
as an aurist, and blow up all the ears indiscriminately that were 
brought to him, he would be a very successful quack.'' Indeed, 
the effects of this means of treatment, especially in the case of 
children, or even adults, who have suffered but a short time 
from impairment of the hearing, from disease of the middle ear. 
are often wonderful. 

Toynbee just missed making the discovery of this method of 
inflating the ear, in his physiological investigations as to the po- 
tency of the Eustachian tube, and especially when he proved 
that it was opened by the act of swallowing. Politzer evidently 
followed Toynbee's investigations very carefully, and with rare 

1 Die Krankheiten des Ohres. 



34 A SKETCH OF THE 

wisdom availed himself of them to make an invaluable addition 
to our means of treating the ear. 

The late Dr. Julius Erhard (1S63) published a work upon the 
diseases of the ear. 1 which is a peculiar mixture of truth with 
error. Most of its theories are based upon imperfect observa- 
tions and are misleading in the extreme. It has little or no 
practical value. 

In 1864 Dr. von Troltsch. Dr. Politzer, and Dr. Herman 
Schwartze. of Halle, issued the first number of the Archiv. fur 
Ohrenheilkunde, a work which has been regularly continued 
under their management, and which has formed a true guide to 
the otological student and practitioner. 

In 1805 Dr., now Professor, Politzer published a monograph 
upon the membrana tympani. which was translated into English 
and published in the United States by my friends and colleagues 
Drs. Arthur Mathewson and Homer P. Xewton. of Brooklyn. 
This monograph was the first serious study of the drum-head, 
and holds a high place in otological literature. 

In October, 1807. the first number of the Monatsschrift fur 
Ohrenhe ilk uncle was issued, under the direction of Dr. Voltolini, 
of Breslau ; Dr. Josef Gruber, of Vienna : Dr. F. E. Weber, of 
Berlin ; and Dr. X. Rudinger, of Munich. This journal is still 
continued, with the addition of a department devoted to diseases 
of the throat. All of these editors have contributed very much 
to the scientific advance of otology ; while Dr. Rudinger has 
probably done more than any anatomist of his day to elucidate 
the anatomy of the Eustachian tube. His photographic atlas of 
the ear is a work of permanent value, and one of which the 
author has made frequent use in illustrating some of the chap- 
ters of this work. 

Dr. S. Moos. 2 of Heidelberg, issued a practical treatise on aural 
disease in 1866, and Dr. Gruber, 3 of Vienna, one in 1870. Both of 
these volumes show much original research, and are worthy of 
an English translation, which would bring them before a much 
larger circle of readers. 

The American Otological Society was established in 1868, and 
has held annual meetings since, and has published thirteen vol- 
umes of " Transactions." To these papers the author has had fre- 
quent occasion to refer in the preparation of the following chap- 
ters, and it is believed that they furnish evidence of the high 
character of the work that has been clone by American otologists. 

1 Klinisclie Otiatrie. Berlin. 

2 Klinik der Ohrenkranklieiten. 

3 Lelirbucli der Okrenlieilkunde. 



PROGRESS OF OTOLOGY. 35 

No outline of what has been done in the last twenty years 
for otology would be complete without a reference to the writ- 
ings of the late Professor Edward H. Clarke, of Harvard Uni- 
versity. Dr. Clarke published a paper on perforations of the 
membrana tympani, 1 its causes and treatment, which was prob- 
ably the best that had been written on this subject. It received 
a full recognition among foreign authorities. This article con- 
tains a very important sentence, quoted by Troltsch in his text- 
book, a passage full of meaning and warning : " So necessary is 
a careful attention to the ear, during the course of an acute ex- 
anthema, that every physician who treats such a case without 
careful attention to the organ of hearing, must be denominated 
an unscrupulous practitioner." Dr. Clarke also published a 
monograph upon polypus of the ear, which contains very much 
of value as to the nature and treatment of these products of in- 
flammation. 

In 1869, Drs. H. Knapp, of New York, and S. Moos, of Heidel- 
berg, began the publication of the Archives of Ophthalmology 
and Otology, which are issued simultaneously in English and 
German, and which have added much to the scientific interest 
in otology. The union of the two branches of science in so 
valuable a journal has certainly assisted to gain the respect of 
the profession for the department of otology. In 1879 these pub- 
lications were separated, and the author of the present work 
became associated with Drs, Knapp and Moos in the publication 
of the journal devoted to otology. 

In 1872, Dr. Laurence Turnbull issued a "Clinical Manual of 
the Diseases of the Ear." In 1873, the first edition of the present 
treatise on the ear was published. In the same year Mr. W. B. 
Dalby, of London, published a volume of lectures upon the ear, 
which is of permanent value. The work of Dr. A. D. Williams, 
of St. Louis, was also published in this year, and contains many 
original observations. 

Dr. Weber Liel's 2 (1873) work upon the nature and curability 
of progressive impairment of hearing, is a monograph which has 
been subjected to close analysis and criticism on the one hand, 
and from which much has been borrowed on the other. It is an 
ingenious and interesting work, but, in the opinion of the au- 
thor of this work, its theories have not been substantiated. 

In Italian, the work of Dr. De Rossi 3 (1871) is written in the 



1 American Journal of the Medical Sciences, January, 1858. 

2 Ueber das Wesen und die Heilbarkeit der luiuligsten form progressiver Selnveho- 
rigkeit. 

3 Le Mallattie dell' Orecchio. 



36 A SKETCH OF THE 

spirit of the modern German school, and forms a reliable guide 
to those reading that language. 

One of the most valuable works that has ever been published 
upon diseases of the ear is the one entitled " The Questions of 
Aural Surgery," by the late James Hinton (1874). It is written 
in a purely scientific spirit, and is full of valuable facts and 
wise observations, while it suggests much for more thorough 
investigation. It was accompanied by an atlas of the mem- 
brana tympani, consisting of one hundred and fifty pictures 
of the drum-head in water-color. Literature must be searched 
very carefully to find a scientific work upon any subject so 
essentially honest and impartial as the volume entitled " Ques- 
tions in Aural Surgery." 

The lectures on aural catarrh, by the late Dr. Peter Allen 
(1870), are valuable in many points. The second edition passed 
through the press in 1874, during the author's last illness. The 
death of Dr. Allen was a loss to our profession of a hard- 
working and ingenious student in otology. 

Mr. George P. Field (1876), the successor of Toynbee as Aural 
Surgeon to St. Mary's Hospital, published a small octavo upon 
the ear, which has some unique features, especially in the illus- 
trations of the various forms of diseases of the membrana tym- 
pani, as seen through the speculum. The book contains many 
valuable cases, and is altogether a positive contribution to aural 
medicine and surgery, and has passed into the second edition. 

Among the most valuable of the text-books on the ear of the 
present day is that of Dr. Charles H. Burnett (1877). The part 
upon anatomy and physiology is particularly well presented. 

The monograph upon " Deafness, Giddiness, and Noises in 
the Head," by Dr. Edward Woakes (1879), of London, hardly 
assumes to be a text-book. Its peculiar views are chiefly those 
of Weber Liel of Berlin, and will be alluded to in certain discus- 
sions in this volume. The author is enthusiastic in the promul- 
gation of his views of the causes of aural affections. His work 
has passed to a second edition, and he has adherents in this 
country. 

The work of Dr. H. Macnaughton Jones (1881), of Cork, also 
lays great stress upon Weber Liel's views as to paretic deafness, 
and operations upon the tensor tympani, without, however, any 
claim like that made by Woakes, to have been coeval with the 
latter author in his views upon these subjects. 

The work on the ear by Dr. Albert H. Buck (1880), of New 
York, contains a vast amount of valuable research in otology. 
The author's experience has been large, and every one interested 
in otology will find its pages very interesting and instructive. 



PKOGRESS OF OTOLOGY. 37 

Especially to be mentioned are the sketch of the physiology of 
the ear, the chapter upon the mastoid process, and the one upon 
fractures of the temporal bone. 

Of text-books upon the ear in the French language there is 
very little to be said. Modern otology finds very little comfort 
in such works as those of Miot and Bonnafont, although the 
latter-named author has laid the profession under obligations by 
his contributions to the subject of exostosis. 

Among the recent works in the German language are those 
of Urbantschitsch, of Vienna, Hartmann, of Berlin, and Politzer. 
The work of the first-named author is an elaborate cyclopaedia, 
with scarcely a trace of personal coloring, dreary in the ex- 
treme, but valuable as a work of reference. Politzer's work 
upon the ear is worthy of the expectations raised by the renown 
of its author. It has been translated into excellent English by 
Dr. Patterson Cassells, of Edinburgh, and is accessible through 
an American publisher. 

In 1879, The American Journal of Otology, a quarterly, was 
founded by Dr. Clarence J. Blake in conjunction with a number 
of eminent aural surgeons and physicists. The journal was es- 
tablished in order "to afford a medium for the publication of 
original communications on subjects coming within the scope of 
the two departments to which it was devoted," acoustics and 
aural surgery. This journal was ably conducted, but the publi- 
cation ceased with the fourth volume in 1882. 

There is also a French journal 1 devoted to diseases of the ear, 
in conjunction with those of the larynx, which furnishes many 
original articles as well as a fair digest of foreign literature. 

The latest work on the ear that has appeared up to the time 
of the writing of this chapter, is that by Dr. Oren D. Pomeroy. 
long and favorably known to the profession as an original and 
industrious worker in otology. His volume contains the result of 
the author's large experience, with a compendium of that of 
others, written in a judicial spirit. 

Lincke, writing in 1810, regrets that in Germany no clinique 
for the treatment of aural patients had as yet been organized. 
Dr. Reiner, he says, had attempted to do so in Munich, but had 
failed, as had Dr. Lincke in Leipsic ; and we know that Saun- 
ders and Cooper had failed in establishing one in London ; for 
in 1804, Saunders had an eye and ear infirmary in London, under 
the name of the " New London Dispensary for Curing Diseases 
of the Eye and Ear/' But the aural part was so unsuccessful, 
that it became necessary to close it to the aural practice. John 

1 Annales des Maladies do l'Oreille et du Larynx. 



38 A SKETCH OF THE 

Harrison Curtis, in 1816, was more successful, and when Lincke 
wrote his dispensary was still carried on. In 1828, the New 
York Eve and Ear Infirmary, which had been in existence 
eight years, treated 91 cases of diseases of the ear to 925 of 
diseases of the eye. That institution, according to its last pub- 
lished report, treated more than 2,800 aural cases, while every 
large city of Europe and America now enjoys the benefits of 
institutions where aural diseases are properly and specially 
treated. 

In New York City, there are four special hospitals for the 
treatment of aural diseases, in conjunction with diseases of the 
eye — a union which seems to find favor chiefly in the United 
States, Ireland, and Canada. 

The marked distrust with which the profession at large re- 
garded the theories of the nature and treatment of aural disease, 
did not begin to give way until the views of Wilde became gen- 
erally known and accepted. It was not, however, until a simple 
and practical means of examining the auditory canal and mem- 
brana tympani had been suggested and accepted, that otology 
became an inviting field of professional labor. 

The next step was to recognize the pharynx as the starting- 
point of the diseases of the middle ear, and to separate these 
from the less frequently occurring cases of diseases of the ex- 
ternal ear. With this came a simple means of opening and 
treating the Eustachian tube and the tympanic cavity. If now, 
we can succeed as I believe we are about to succeed, in separat- 
ing affections of the nerve from those of the middle ear, that 
is to say, diseases of the perceptive apparatus from those of 
the parts devoted to the conduction of sound, otology will take 
rank with ophthalmology for exactness in diagnosis and prog- 
nosis. 

If any cause remain for looking askance at the claims of 
otology, it is to be found in the attitude of those otologists who, 
in a spirit quite out of keeping with true medical philosophy, 
devote too much of their energy to the explication of the 
causes and treatment of incurable aural diseases, and who lay 
too little stress upon recent affections and the hygienic knowl- 
edge which may prevent insidious and incurable diseases of the 
ear, and who reject all attempts at an exact diagnosis of affec- 
tions of the labyrinth, declaring themselves agnostics, at a time 
when faith and works may bring to us a knowledge of what they 
declare to be beyond human ken. 

In concluding this introductory chapter, I beg that the reader 
will bear in mind that I have not attempted to make it more 
than an outline of what has been done in otology from the earli- 



PROGRESS OF OTOLOGY. 39 

est times until our own day. I have endeavored to sketch only 
that which has left its traces upon the science, and which has 
contributed materially to its progress. I have merely desired to 
give such a historical account of the work of the fathers, as 
would render any frequent references to them unnecessary in 
the body of this work, and one which may be a guide and en- 
couragement for those who are interested in this department of 
medicine. 



AUTHOEITIES CONSULTED IN PEEPAEING THE PEECEDING HIS- 

TOEICAL SKETCH. 

For the convenience of the reader who may desire to consult the original authorities which the author 
has examined in preparing the preceding sketch, their complete titles are here given. The bibliography- 
will, however, be seen to refer only to the works actually examined, and not to those mentioned as quoted 
by the authorities themselves. 

Archiv f lir Ohrenheilkunde. Herausgegeben von A. Von Troltsch, A. Politzer, 
und H. Schwartze. Wurzburg. I.-VL, Neue folge I.-XIX. 

Archives of Ophthalmology and Otology. Edited and published simultaneously 
in English and German, by Professor H. Knapp, in New York, and Profes- 
sor S. Moos, in Heidelberg. New York : William Wood & Co. Carlsruhe : 
Chr. F. E. Mullersche Hof - Buchhandlung, 1869-72. 

Archives of Otology. Edited in English and German by Dr. H. Knapp, Dr. S. 
Moos, and Dr. D. B. St. John Eoosa. 

Allen, Petee. Lectures on Aural Catarrh. London : J. & A. Churchill, 1871. 

The Same. Second edition. 1874. 

American Journal of Otology. Edited by S. Clarence J. Blake, in conjunction 
with Professor A. M. Mayer, of Hoboken ; Alexander Graham Bell, Dr. 
Elliott Coues, U.S.A., Professor A. Dolbear, Dr. Albert H. Buck, Dr. 
Samuel Sexton, Dr. J. Orne Green, Dr. H. N. Spencer. New York : 1879- 
1883. 

Annales des Maladies de l'Oreille et du Larynx. Fondees et Publiees par MM. 
Ladreit de Lacharriere, Isambert, D. Kreishaber. Paris : G. Masson, 
Editeur. 

Beck, Kabl Joseph. Die Krankheiten des Gehoerorganes. Heidelberg und 
Leipzig, 1827. 

Burnett, Chaeles H. The Ear : Its Anatomy, Physiology, and Diseases. Phila- 
delphia : Henry C. Lea, 1877. 

Buck, Albeet H. Diagnosis and Treatment of Ear Diseases. New York : 
William Wood & Co., 1880. 

Bonnafont, De. I. P. Traite theorique et pratique des Maladies de l'Oiville et 
des Organes de l'audition. Deuxieme edition revue et augmented. Paris : 
J. B. Balliere et Fils, 1873. 

Biographie Medicale. Tom. I. -VII. Paris : C. L. F. Panekoueke. 

Beeschet, Gilbeet. Eecherches anatomiques et physiologiques sur l'Org&ne Jo 
l'ouie et sur l'audition, dans l'homme et les animaux vertcbres. Deuxiome 
edition. Paris : J. B. Balliere, 183b\ 



40 A SKETCH OF THE 

Clarke, Edward H. American Journal of the Medical Sciences, January, 1858. 
Clarke, Edward H. Observations on the Nature and Treatment of Polypus of 

the Ear. Boston, 1867. 
Cotunnh, Dominick, Ph.D. et M.D. De aquaeductibus auris humane internae. 

Anatomica Dissertatio. Viennae : apud Eudolphum Graeffe, 1774. 
Curtis, John Harrison. A Treatise on the Physiology and Diseases of the Ear. 

Third edition. London and Edinburgh, 1823. 
Cyclopaedia of Anatomy and Physiology. London : Longman, Brown, Green & 

Longmans, 1839. Article, "The Organ of Hearing." 
Dunglison, Eobley. History of Medicine, from the earliest ages to the com- 
mencement of the nineteenth century. Philadelphia : Lindsay & Blakis- 

ton, 1872. 
Du Verney. Tractatus de organo auditus, continens structuram usum et mor- 
bus omnium auris partium. Norimbegae, 1681. 
Dalby, W. B., F.B.C.S., M.B. Cantab. Lectures on Diseases and Injuries of 

the Ear. London : James A. Churchill, 1873. 
Encyclopaedia, Chambers's. Philadelphia : J. B. Lippincott & Co., 1872. 
Encyclopaedia Britannica. Ninth edition. New York : Charles Scribner's Sons. 
Eustachii Bartholom^ei. Sanctose vermatis medici ac philosophi opuscula 

anatomica. Venetiis, 1563. 
Ely, Edward T. Ophthalmic and Otic Memoranda. By D. B. St. John Boosa 

and Edward T. Ely. Bevised edition. New York: William Wood & Co., 

1880. 
Erhard, Julius. Klinische Otiatrie. Berlin : A. Hirschwald, 1863. 
Field, George P., M.B. OS. Diseases of the Ear. Second edition. London: 

Henry Kenshaw, 356 Strand, 1879. 
Fabricius de Acquapendente. Opera Omnia Anatomica et Physiologica. Lug- 

duni Batavorum, 1738. 
Frank, Martell. Practische Einleitung der Erkentniss und Behandlung der 

Ohrenkrankheiten. Erlangen, 1845. 
Gruber, Josef. Lehrbuch der Ohrenheilkunde. Wein, 1870. 
Hartmann, Dr. Arthur. Die Krankheiten des Ohres. Kassel : Theodor 

Fischer, 1881. 
Helmholtz, H. Die Lehre von den Tonempfindungen als Physiologische 

Grundlage fur die Theorie der Musik. Vierte umgearbeitet ausgabe. 

Braunschweig, 1877. 
Hartmann, Arthur. Deaf Muteism and the Education of Deaf Mutes by Lip- 
reading and Articulation. Translated and enlarged by James Patterson Cas- 

sells, M.D. London : Balliere, Tindale & Cox, King William Street, 

Strand, 1881. 
Henle, J. Handbuch der Menschen. Bd. II. Braunschweig, 1866. 
Herodotus. A new and literal version from the text of Baehr. By Henry 

Cary, M.A. London : Henry G. Bohn, 1854. 
Hinton, James. Atlas of the Membrana Tympani, with descriptive text. Being 

illustrations of diseases of the ear. London: Henry S. King & Co., 65 

Cornhill and 12 Paternoster Bow, 1874. 
Hinton, James. The Question of Aural Surgery. London : Henry S. King & 

Co., 1874. 
Itard, J. M. G. Die Krankheiten des Ohres und des Gehors. Aus dem Fran- 

sosichen. Weimar, 1822. 



PROGRESS OF OTOLOGY. 41 

Jones, T. Wharton. The Organ of Hearing, in Cyclopaedia of Anatomy and 

Physiology. Vol. II. London, 1839. 
Jones, H. Macnaughton, M.D., M.A., F.R.C.S. I. and Edin. A Treatise on 

Aural Surgery. Second edition, revised and enlarged. Philadelphia : 

Presley Blakiston, 1882. 
LrNCKE, Carl Gustav. Handbuch der Theoretischen und Praktischen Ohren- 

heilkunde. Bel. I., II. Leipzig, 1837-1840. 
Kramer, W. Die Ohrenheilkunde der Gegenwart (1860). Berlin, 1861. 
Kramer, W. The Aural Surgery of the Present Day. Translated by Henry 

Power. London : New Sydenham Society, 1863. 
Kramer, W. Handbuch der Ohrenheilkunde. Berlin, 1867. 
Kramer, W. Ohrenkrankheiten und Ohrenaerzte in Deutschland und England. 

Ein Nachtrag zur Ohrenheilkunde der Gegenwart. Berlin, 1865. 
Kramer, W. Die "exakten" deutschen Ohrenarzte. Berlin, 1871. 
Miot, Dr. C. Traite Pratique des Maladies de l'Oreille, ou lecons cliniques sur 

les affections de cet organe. Paris : F. Savy, Libraire-Editeur, 24 Bue 

Hautefeuille, 1871. 
Monatsschrift far Ohrenheilkunde. Herausgegeben von Dr. Voltolini, Dr. Josef 

Gruber, Dr. U. Rudinger, und Dr. F. E. Weber. 
Monro, Alexander. Three Treatises on the Brain, the Eye, and the Ear. Eelin- 

burgh, 1797. 
Moos, S. Klinik der Ohrenkrankheiten. Wien : W. Braumiiller, 1866. 
Nottingham, John. Diseases of the Ear. Illustrated by clinical observations. 

London : John Churchill, 1857. 
Pilcher, George. Treatise on the Structure, Economy, and Diseases of the 

Ear. By George Pilcher. First American from the second London edition. 

Philadelphia : Ed. Barrington and Geo. D. Haswell, 1843. 
Politzer, Adam. Die Beleuchtungsbilcler des Trommelfells in Gesunden und 

Kranken Zustande. Wien : Wilhelm Braumiiller, 1865. 
Politzer, Adam. The Membrana Tympani in Health anel Disease, etc. With 

Supplement. Translated by A. Matthewson, M.D., and H. G. Newton, M.D. 

New York : William Wood & Co., 1869. 
Politzer, Adam. Lehrbuch der Ohrenheilkunde fur Practische Arzte und Studi- 

ende. Bande I. und II. Stuttgart, 1882. 
Politzer, Adam. A Text-Book of the Diseases of the Ear and Adjacent Organs. 

Translated and edited by James Patterson Cassells, M.D., M.R.C.S., Eng. 

Philadelphia : Henry C. Lea's Son & Co., 1883. 
Pomeroy, Oren D. The Diagnosis and Treatment of Diseases of the Ear. New 

York : Bermingham & Co., 1883. 
Bossi, De. Le Malattie dell' Orecchio. Trattato Teorico, Pratico. Genova, 1871. 
Rau, Dr. Wilhelm. Lehrbuch der Ohrenheilkunde. Berlin : Verlag von H. 

Peters, 1856. 
Saissy, J. A. An Essay on the Diseases of the Internal Ear. Translated from 

the French by Nathan R. Smith, M.D. With a Supplement on Diseases of 

the External Ear by the Translator. Baltimore, 1829. 
Saunders, John Cunningham. The Anatomy of the Human Ear. Illustrated by 

a series of engravings of the natural size, with a treatise on the diseases of 

that organ, the causes of deafness and their proper treatment. First Ameri- 
can, from the second London edition. With notes and additions by Wm. 

Price, M.D. Philadelphia : Benjamin Warner, 1821. 



42 A SKETCH OF THE 

Schwaetze, H. Die Wissenschaftliclie Entwicklung der Okrenkeilkunde, Ar- 
chiv fiir Olirenlieilkunde, Bd. I. 

Schwaetze, Pbofessoe H. Patkologisclie Anatoinie des Okres. Kleb's Hand- 
buck der patkologiscken Anatomie. Berlin, 1878. 

Schwaetze, H. Translation of tke above, by J. Obne Gbeen, A.M., M.D. Bos- 
ton : Hougkton, Osgood & Company, 1878. 

Shbapnell, Henbt Jones. On tke Form and Structure of tke Membrana Tym- 
pani, p. 120 ; on tke Function of tke Membrana Tympani, p. 282 ; on tke 
Nerves of tke Ear, p. 505 ; tke London Medical Gazette, vol. x., April 7, 1832, 
to September 29, 1832. London, 1832. 

Soemmering, Sam. Thom. Icones organi-auditus-kumani. Frankfort a. M., 1806. 

Steickee, S. Handbuck der Lekre den Geweben, des Menscken und des 
Tkieres. Leipzig, 1869-1871. 

Steickee, S. A Manual of Histology. Translated by Henry Power and otkers. 
American translation. Edited by Albert H. Buck. New York, 1872. 

Transactions, Pkilosopkical, of tke Boyal Society of London. For tke years 
1800, 1801. 

Transactions of tke American Otological Society. Vols. I. -III. 

Totnbee, Joseph. A Descriptive Catalogue of Preparations Illustrative of tke 
Diseases of tke Ear, in tke Museum of Josepk Toynbee, F.B.S. London, 
1857. 

Totnbee, Joseph. Tke Diseases of tke Ear, tkeir Nature, Diagnosis, and Treat- 
ment. (Beprint.) Pkiladelpkia, 1860. 

Totnbee, Joseph. Tke Same, with a Supplement by James Hinton. London, 
1871. 

Teoltsch, von Anton. Die Anatomie des Okres, in ikrer Anwendung auf dem 
Praxis. Wtirzburg, 1861. 

Teoltsch, von Anton. Die Krankkeiten des Okres. Ikre Erkentniss und Be- 
kandlung. Wiirzburg, 1862. 
Tke Same, 4 Aufgabe. 

Teoltsch, von Anton. Tke Diseases of tke Ear, tkeir Diagnosis and Treatment. 
Translated into Englisk by D. B. St. Jokn Boosa. New York : William 
Wood & Co., 1864. 

Teoltsch, von Anton. Treatise on tke Diseases of tke Ear, including tke 
Anatomy of tke Organ. Second edition, from tke fourtk German. Trans- 
lated and edited by D. B. St. Jokn Boosa. New York : William Wood & 
Co., 1869. 

Teoltsch, von Anton. Gesammelte Beitrage zur Patkologiscken Anatomie des 
Okres. Leipzig, 1883. 

Tuenbull, Lawbence. A Clinical Manual of tke Diseases of tke Ear. Pkiladel- 
pkia : J. B. Lippincott & Co., 1872. 

Uebantschttsch, De. Victoe. Lekrbuck der Okrenkeilkunde. Wien und Leip- 
zig : Urban & Sckwarzenberg, 1880. 

Valsalva? Opera. Viri celeberinni Antonii Maria?. Tractatus de Aure Humana. 
. . . . Omnia recensuit et auctoris vitam addivit Joannes Baptista 
Morgagnus. Lugduni : Batavorum apud Jokannem Hasebroek, 1742. 

Wilde, William B. Some Observations on tke Early History of Aural Surgery, 
and tke Nosological Arrangement of Diseases of tke Ear, by W. B. Wilde, 
M.B.I. A. Tke Dublin Journal of Medical Science, Vol. XXV. Dublin, 1844. 

Wilde, William B. Practical Observations on Aural Surgery, and tke Nature 



PROGRESS OF OTOLOGY. 43 

and Treatment of Diseases of the Ear, by William K. Wilde. London : John 

Churchill, 1853. 
Weber Liel, Dr. Fr. E. Ueber das Wesen und die Heilbarkeit der haufigsten 

form progressiver Schwerhorigkeit-TJntersuchungen und Beobachtungen. 

Berlin : August Hirschwald, 1873. 
Williams, Joseph. Treatise on the Ear, including its Anatomy, Physiology, 

and Pathology. London : John Churchill, 1840. 
Williams, A. D. Diseases of the Ear. Including the necessary anatomy of the 

organ. Cincinnati : Robert Clarke & Co., 1873. 
Willis, Thomas. Opera Omnia. Amsterdamna apud Henricum Wetstenium. 

Pars Physiologica, Cap. XIV., p. 69. 
Woakes, Edward, Lond. On Deafness, Giddiness, and Noises in the Head. 

Second edition, enlarged and revised. London : H. K. Lewis. 136 Gower 

Street, W. C. 
Yearsley, James. Deafness Practically Illustrated. Being an Exposition of 
• the Nature, Causes, and Treatment of Diseases of the Ear. Sixth edition. 

London : John Churchill & Sons, 1863. 



CHAPTER II. 

THE EXAMINATION OF AURAL PATIENTS. 

History. — Power of Hearing Conversation. — Test Sentences. — Tick of a Watch. — Tun- 
ing-fork. — Aerial and Bone Conduction. — Malingering. — Angular Forceps. — 
Specula. — Tr5ltscli's Otoscope. — Examination of Pharynx. — Rhinoscopy. — Use of 
Eustachian Catheter. — Politzer's Method and its so-called Modifications. — Bou- 
gies. — Valsalva's Method. 

It is a self-evident proposition, that in order to intelligently 
treat any disease we must carefully and thoroughly examine 
the parts involved. This is certainly as true of the affections of 
the ear as it is of those of any other organ. In making such an 
examination a definite plan should be followed, even in the 
seemingly simple cases, until at last a large experience enables 
the practitioner to omit or hurry over some of the details which 
were necessary in the beginning of his practice. 

In the examination of an aural patient, the following method 
is the one that I have found very useful : — I usually keep a 
record of the cases ; a plan which the young, and consequently 
not very busy practitioner will find extremely valuable. The 
name, age, and occupation of the patient are noted. The history 
should then be given. This history should include a pretty full 
statement of the general condition, the diseases from which the 
patient has suffered, the number of times he has had what is 
called "earache," the medication to which he has been sub- 
jected, and so on, from his earliest recollections until the date 
of his coming under observation as an aural patient. 

By no other means than by eliciting such a history, can the 
practitioner get the essential knowledge for a thorough under- 
standing of the subjective manifestations of the affection of the 
ear. It is very important to ascertain when the troublesome 
symptoms were first observed. Sometimes several minutes will 
be consumed in obtaining an answer to this question. The first 
reply will be, perhaps, "A few months ago," or, "A year or 
two." If this response be followed by the inquiry, " Before that 
time were your ears perfectly well ? " in many instances the pa- 
tient will state, " Well, no. I have had a little dulness of hear- 



THE EXAMINATION OF AURAL PATIENTS. 45 

ing on one side for ten or twelve years, or for a good while r ' 
(which proves to be a number of years) ; or perhaps he says, 
•'There has been a little discharge from that ear, 'which didn't 
amount to much,' ever since I had the scarlet fever or the 
measles."' As illustrative of this point, I may mention a case 
which lately came to my clinic. The patient, an old man, gave 
the following history : While sitting quietly by the fire, blood 
began to run from his ears, until he had lost quite an amount ; he 
stated positively that this was the first time in all his long, life, 
that he had ever had any kind of an affection of the ear, and 
that he could imagine no cause for it. On close examination in 
the manner of questioning above indicated, he admitted that he 
had suffered from a " slight running from the ears, which didn't 
signify, ever since he was a child." An inspection of the or- 
gans showed that both membranse tympani were removed by 
ulceration, and that large granulations existed. These condi- 
tions of course accounted for the seemingly mysterious hemor- 
rhage, to which the patient could assign no cause. 

It is well in obtaining the history to allow the patient to tell 
his own story, occasionally interrupting him, as may be neces- 
sary, in order to keep him to the matter in hand. After having 
thus obtained as accurate an account as possible, the next step 
is to test the power of hearing. 

The tests of the hearing power usually employed are : 

1. Ordinary conversation. 

2. The tick of a watch. 

3. The tuning-fork. 

Many attempts have been made to produce an instrument 
that will so accurately test the hearing power as to supersede 
the imperfect tests that even all these three constitute. As yet 
success has not been attained. Politzer, 1 after admitting that 
the instruments as yet invented are useless for the precise esti- 
mation of the degree of impairment of hearing, describes his 
own acoumeter. In this instrument the tone is produced by the 
striking of a hammer upon a steel cylinder, which is connected 
by a screw with a perpendicular vulcanite column. I have 
tested it thoroughly, but I see no advantage in it over a watch. 
if the latter be carefully tested, so that the average distance at 
which it can be heard by persons with good hearing power is 
known. 

The power of hearing conversation, perhaps tells the most 
about a person's practical hearing power, and yet it is difficult 
to test it. About the best test of the hearing power that wo 

1 Text-book. English translation, p. 103. 



46 TEST SENTENCES. 

have, is the one which shows the patient's capability for hearing 
what is said in social intercourse, at the table, in the drawing- 
room, and so on. Inasmuch, however, as practitioners, espe- 
cially those who live in large cities and towns, have not always, 
or even usually, the opportunity of making such a test of their 
patient's hearing capabilities, and since the amount of this 
power, although it may be appreciated by the observer himself, 
cannot be made clear to one who simply reads the case, we are 
obliged, in recording the histories of patients, to be content with 
noting at what distance words can be understood when they are 
directed to the person observed, with his face so placed that he 
cannot see the mouth of the speaker. This latter precaution is 
an essential one, since all persons with impaired hearing soon 
learn to watch the lips of the speaker, in order to compensate 
for their loss of hearing power. 

Dr. A. H. Buck ' has made an attempt to furnish test sentences 
so that all the members of any one group or class should be as 
nearly as possible equal in value in penetrating power. Ex- 
amples of such equivalent test sentences are given by Dr. Buck, 
as follows : 

1. Pour oil on the waters of Lake Erie. 

2. All hail ! thou hero of fourteen wars. 

Each of these sentences contains eight long vowel sounds 
and are equally free from non-resonant, consonant, or short 
vowel sounds. 

Dr. Buck 2 has found, however, that the objections to these 
test sentences are practically insurmountable, and he does not 
think they can be made available to any extent ; yet in a rude 
way, I think we may make them of use. I come more and 
more to the use of this test of words spoken as near as may 
be in an ordinary tone, as being the one that conveys the best 
idea of the hearing power. On the other hand, I am more and 
more distrustful of the watch as a means of testing the hearing. 
This remark applies also to the acoumeter. I shall long re- 
member the critical remark of a boy once under my care for 
impaired hearing, who after submitting for some time with pa- 
tience to a test of his power of hearing a watch tick, finally ex- 
claimed : "I don't care to hear the watch ; what I want to hear 
is what people say to me." Since this incident, I have endeav- 
ored to learn the capability of the patient to hear conversation 
under ordinary circumstances by a test of the hearing power, 
and when I wish to demonstrate an improvement, I induce a 

1 Report of the First International Otological Society. New York: Appleton, 1877. 

2 Treatise on the Ear, p. 18. 



TESTING HEAEING BY A WATCH. 47 

friend of the patient to converse with him, under conditions the 
same as those that existed before the improvement took place. 

In testing the hearing by means of the watch, it should be 
first placed at a distance at which its ticking cannot be heard 
by the patient, and then gradually approached to a situation 
where the ticks can be accurately counted. The latter may 
fairly be considered as the farthest point of distinct hearing. 
The hearing power is sometimes tested by placing the watch 
where it can be certainly heard and then withdrawing it to the 
furthest limit at which its sound can be perceived. This is a 
fallacious test, for the sound once perceived, it is easy for a de- 
fective ear to follow it until it reaches a distance far beyond its 
normal range of hearing. The ear which is not being tested 
should be closed by the hand during the examination. It is not 
possible to state the distance at which a watch should be heard 
by a healthy ear, for the simple reason that different watches 
may be heard at different distances, so varying is the distinct- 
ness of the tick. It may be approximately stated, however, that 
an ordinary ticking watch should be heard, by a person with 
average hearing power, at least four feet. To this rule there 
are, however, many exceptions. For instance, I know a medical 
gentleman in this city, who, as tested by the ordinary transac- 
tions of professional and social life, is not at all hard of hearing, 
who cannot hear a watch of common tone more than six inches. 

The discrepancy in the power of hearing the watch and or- 
dinary conversation, as was shown by the author in a paper 
published in the American Journal of the Medical Sciences, is 
so marked as to render the tick of a watch almost useless for 
determining the hearers power in many cases. 

In testing the hearing power by means of a watch it is well 
to remember, as Von Troltsch suggests, that all watches are 
heard better immediately after they are wound, and also that 
the intensity of their sound is increased by holding them so 
that the surgeon's hand covers the back, or when they are held 
by the patient's own hand. In the two latter instances the cause 
of the increased clearness of the tick is, in the one case, the re- 
tardation of the reflection of sonorous waves from the watch. 
and in the other, the conducting power of the patient's own arm 
as it is stretched out. The use of a tape or other measurer, to 
note the number of inches at which the watch is hoard, is indis- 
pensable for an accurate record of a case. The measure should 
not be used, however, until the distance lias been ascertained 
without it. When the patient cannot hear the watch at any dis- 
tance from the ear, it should be laid or pressed upon the auricle. 
mastoid process, or forehead. Before using a watch for the pur- 



48 REGISTER OF HEARING- POWER. 

pose of testing the hearing power of diseased ears, we should 
carefully ascertain how far it may be heard by persons whose 
hearing is unimpaired. 

Dr. J. S. Prout, Surgeon to the Brooklyn Eye and Ear Hos- 
pital, has greatly facilitated our means of recording the hearing 
power, by a simple method, which is somewhat analogous to 
that used in estimating the acuteness of vision ; but, as Dr. 
Prout says : ' "The accuracy with which we measure the visual 
power by Snellen's test types, and record the results obtained, 
cannot be arrived at by means of any of the usual sound-makers 
(sonofactors) ; nor will it be until an instrument can be made 
which shall always produce uniform tones." Dr. Prout recom- 
mends a formula for registering the hearing power, which he 
describes as follows : "For nearly three years I have recorded 
the hearing power as a fraction, the numerator of which is the 
distance at which the particular sound is heard, the denominator 
the distance at which it should be heard by an ear of good aver- 
age hearing power. This denominator must vary according to 
the sonofactor used, and should generally be expressed in 
inches. 

"For still further simplification, and that the method may 
be adapted to international use, I suggest the following abbre- 
viations : A. D., auris dextra, instead of right ear, or R. E. ; 
A. S., auris sinistra; P. A., P. aud., potentia auditus, hearing 
power; V., vox, the spoken voice ; V. S., vox susurrata, whis- 
pered voice — or simply S., susurrus, a whisper ; H., horologium, 
the watch. 

" If this system should become general, then the formula 
P A, A D, H, = Jf, would to all otologists represent the fact that 
a watch that should be heard at 36 inches was heard by the 
right ear of the patient at a distance of 12 inches ; the formula 
P A, A S, V S, = A , would mean that the whispered voice was 
heard by the left ear at 6 inches that should have been heard at 
36 inches." 

Dr. Prout's method is now universally employed. My own 
watch can be heard by a person with good hearing power at 
least 48 inches. It will be seen that if I wish to express the 
hearing power of a person who hears that watch one inch, I 
would use the fraction ■£-$, and so on. If the patient only hears 
the watch when brought in contact with the ear, we may em- 
ploy the formula ¥ c g ; if only on pressure, ^ ; if not at all, -fa ; if 
on the mastoid, ^. 

The objects to be gained by testing the hearing power* are, of 

1 Boston Medical and Surgical Journal, February 29, 1872. 



TEST BY WATCH AND CONVEBSATION. 



49 



course, to learn when a patient is first seen how much his hear- 
ing power is impaired, and as he continues under treatment 
whether or not any improvement has taken place. If the watch 
alone be used for this purpose, there are many opportunities for 
error in opinion. For example, some patients, especially chil- 
dren, readily imagine they hear the ticking of a watch when 
they do not. Adults who are very much troubled by tinnitus 
aurium also fall into this kind of error. In testing one ear with 
the watch we should be careful to exclude the other, for sound 
readily passes through the bones of the head, or the air, or both, 
to the other ear. Especially is this the case when one ear is so 
much affected that it is only heard when pressed upon the mastoid 
process (/ s ), or not at all (£%). I think it is true that patients 
affected with certain forms of disease of the acoustic nerve, 
hear a watch relatively much worse than they do conversation. 



Table showing the Disproportion betiveen the Power of Hearing 
the Tick of a Watch and the Human Voice. 1 




1 American Journal of the Medical Sciences, Vol. Ixxiii., p. 50. 
4 



TICK OF A WATCH. 



Table showing the Disproportion between the Power of Hearing 
the Tick of a Watch and the Human Voice. — (Continued.) 



No. 


Sex and age. 


Hearing distance for the watch. 


Hearing distance for conversation, the pa- 
tient being with the back to the speaker. 


18 


Male, 45. 


"R _4_ T, pressed 
SX ' 4 0> 1J ' ~4lT^ 


Conversation at 40 feet. 


19 


Male, 54. 


xu 4 0' ^ 4 ' 


Loud conversation at 45 feet. 


20 


Male, 70. 


"R pressed T , laid 
-El- "Jo-) -Ll- Jo* 


Conversation at 30 feet. 


21 


Female, 16. 


E. 4 3 0> L- ft- 


Voice with difficulty at 10 feet. 


22 


Male, 80. 


ft- A, L- J» 


Conversation at 40 feet. 


23 


Male, 32. 


ft. A* L - 4-V 


Conversation at 30 feet. 


24 


Male, 36. 


T> contact T mastoid 


Ordinary conversation at 18 feet. 


25 


Female, 24. 


ft- A L- A ' 


Conversation at 10 feet. 


26 


Male, 74. 


- Ll - 4 0' J - i# 4 0* 


Conversation at 50 feet. 


27 


Female, 15. 


R. ^, L. T V 


Ordinary conversation at 40 feet. 


28 


Male, 71. 


R Jfc L. ^. 


Conversation at 20 feet. 


29 


Male, 44. 


ft- ft L «. 


Conversation at 30 feet. 


30 


Female, 22. 


E , ±i* T, _3_ 
xv. 4(J , _u. 40 . 

After removal of ceru- 


Conversation at 26 feet. 






men and inflation. 


Conversation at 30 feet. 


31 


Male, 38. 


R. J, L. pressed. 


Conversation at 20 feet. 


32 


Male, 13. 


"R. 3.3 f. _7_ 
-*- 1 - 4 0' - LJ " 4 0' 


Conversation at 30 feet. 


33 


Male, 21. 


K, jV. L. fJfA 


Loud conversation at 8 feet. 


34 


Male, 33. 


B. jfr l. ¥ y 


Conversation at 50 feet ; general 
conversation with ease ; does 
not hear high notes well. 


35 


Female, 17. 


E. &, L. A. 


Conversation with some difficulty 
at 30 feet. 


36 


Female, 34. 


T> pressed T laid 
**. ' 40 , -U. 4-Q. 


Loud conversation at 6 feet. 


37 


Female, 37. 


j- 11 . 4 ' - LJ * 4 • 


Distinct voice at 2 feet. 


38 


Female, 36. 


"D laid T laid 
- tt " 40' - Lj " 40/ 


Voice at 34 feet after use of arti- 






After use of artificial 


ficial membranse tympanorum. 






membranes, R, 4 3 y, L. J 1 ^. 





The tick of a watch is produced by the striking of a little 
hammer upon the apex or side of the tooth of a ratchet-wheel. 
It is therefore a simple unvarying tone, modified as to quality 
in different watches. Now the sounds produced by the vocal 
cords, reinforced by the resonating cavities of the nose and 
mouth, may pass through a range of musical notes, which, as in 
the case of the late Madame Parepa Rosa, may compass three 
full octaves. A mere regular sound, such as that of the watch, 
is certainly in no sense to be compared to the musical tones of 
that wonderful instrument the human larynx. If, however, the 
power of hearing the watch tick stood in any definite and fixed 
relation to the ability to hear ordinary conversation, it would 
serve very well as a test for registration. If, for example, we 



51 

were able to say that a person who has a hearing distance by 
the watch of f £, has a degree of hearing sufficient for the duties 
of life, that it is as adequate as f g- as tested by Snellen's test- 
types is for seeing, the statement would give us a definite idea 
of just how much the hearing power is impaired. But a refer- 
ence to the table shows that the power of hearing the tick of a 
watch stands in no exact proportion to the power of hearing con- 
versation. On the other hand, the test by the voice is also in- 
adequate. When a person is waiting to hear a voice in a quiet 
room, his ability to hear this, when compared with what is de- 
manded of an ear, is utterly inadequate as a test. As is well 
known, a healthy ear can appreciate from seven to eleven oc- 
taves. Probably the life we lead in large cities and towns re- 
quires such a power if we are to hear all that is demanded of us. 
How then can the tones of the larynx, capable at its greatest of 
reaching three octaves, form a sufficient test ? 

Again, as will be shown in a subsequent chapter, a whole 
class of persons suffering from disease of the ears hear better in 
a noise, while another class hear best in quiet places. All these 
things must be taken into consideration in testing the hearing 
power or erroneous conclusions will often be reached. Unre- 
liable as are the statements of patients as regards the history of 
their cases, their testimony as to their improvement or non- 
improvement is always of value in determining the true state of 
the hearing power, and better still are the statements of their 
relatives or friends, who, no matter how great their affection, 
are always annoyed by being obliged to make an effort to make 
them hear. They, at least, will gladly hail and note any greater 
ability to hear on the part of a person with whom they have 
been in the habit of conversing. 

THE TUNING-FORK. 

The value of the tuning-fork in testing the hearing power is 
chiefly in the way of determining whether a given disease be in 
the middle or internal ear. Von Conta, 1 of Weimar, recom- 
mended it some years since, however, as a means of testing the 
hearing power. In his method, the vibrations from the tuning- 
fork are conducted to the ear through an elastic tube. The num- 
ber of seconds during which the gradually decreasing vibrations 
are heard becomes the measure of the hearing power. This 
method never found any great favor, and so far as I know is not 
often employed. 

1 Archiv. fur Ohrenlieilkunde, Bd. L, p. 108. 



52 THE TUNI2s T G-F0KK. 

Since then, however, the tuning-fork has been and continues 
to be widely employed in various ways for the purpose of differ- 
ential diagnosis. I believe we now have in it, by a very simple 
method, a valuable aid to a knowledge of the situation of a 
given lesion. I shall, however, before describing the method 
I now employ to the exclusion of all others in the test with the 
tuning-fork, first give an account of the history of its use in 
aural diagnosis, with a statement of the methods in which it is 
generally used. 

As is well known, if we close our ears, and speak, the sound 
of the voice seems to be confined to the head, as it were ; its re- 
flection being to a certain extent prevented by the closure of the 
external auditory canal. If now the auditory nerve be sound, 
and there be impacted wax in one auditory canal, or a thicken- 
ing of the mucous membrane lining the cavity of the tympanum, 
the state of things will be similar to that when the external 
meatus of a healthy ear is closed by the finger, or by some simi- 
lar means, and the vibration of a tuning-fork placed upon the 
bones of the head will be heard more distinctly by an ear thus 
affected than by the sound one. If the ears are equally affected, 
it will be, of course, more difficult to come to a conclusion. If 
the nerve be seriously impaired, from a primary lesion, or secon- 
darily, by disease which has extended from the middle ear, no 
such marked difference will be noticed when the external meatus 
is closed. 

Again, when the tick of a watch cannot be heard at all, if 
the auditory nerve be not seriously impaired, the vibrations of 
the tuning-fork, when its handle is placed on the teeth, fore- 
head, or mastoid process, will be distinctly heard ; while if the 
nerve be the seat of serious lesion, so that absolute deafness 
exists, these vibrations will not be at all perceived in the head. 
Some deaf-mutes, who were born deaf, and perhaps with a dis- 
ease of the central apparatus, have assured me that they always 
felt the sound of the tuning-fork passing to the region of the 
diaphragm or stomach, and they would involuntarily place their 
hand there when the vibration began. The large tuning-forks 
of the note C are to be preferred to the smaller ones. 

There is one source of error in the use of the tuning-fork in 
this manner that cannot be fully avoided. Patients who do not 
possess fair habits of observation will say that they hear the tun- 
ing-fork better from the ■ better ear, because they think that 
they ought to do so. A little care in urging such persons to 
notice the sound carefully will usually cause a correct answer 
to be given. Its chief value is, however, among persons who 
can be taught to observe what they actually hear, and who 



THE TUNING-FORK. 53 

will allow their theoretical notions to remain in abeyance for a 
time. 

The following case illustrates the old method of using the 
tuning-fork as a means of diagnosis, and also the inadequacy 
of the watch as a test of hearing : 

Dr. W , aged thirty-three, consulted me in regard to an 

uncomfortable, "stuffy" sensation in the right ear, attended by 
a slight impairment of hearing. His history was that he had 
had nasal catarrh for some months ; for two days he has ob- 
served the aural trouble. On testing the hearing power by the 
watch it was found to be normal, or f §, on both sides ; but the 
tuning-fork was heard better on the affected side, and the pa- 
tient, a busy physician and an exact observer, was sure that 
his hearing power was somewhat impaired upon the right side, 
although the watch did not detect it. The membrana tympani 
was slightly injected along the handle of the malleus. 

I diagnosticated the affection as sub-acute inflammation of 
the middle ear of the right side, and treated it by the use of the 
Eustachian catheter, Politzer's method, and a gargle, as well as 
by the application of a leech to the tragus. After the first use 
of the catheter and Politzer's method, the tuning-fork was heard 
with equal distinctness on both sides, thus confirming the diag- 
nosis and illustrating the value of the test. The patient re- 
covered perfectly in a few days ; but at each visit before the ear 
was inflated until his ear was fully restored to the normal con- 
dition, the tuning-fork was heard more distinctly on the affected 
side. 

As has been previously intimated, I no longer employ the 
tuning-fork in this manner for the purpose of making a diag- 
nosis, but I rely upon the statements of the patient as to whether 
the tuning-fork is heard more distinctly and for a longer time 
when its vibrations are conducted through the air or through the 
bones of the head. It is much easier for any person to determine 
whether he hears a tuning-fork when held in front of the ear 
better or worse than he does when it is placed on the mastoid 
process, than it is for him to say on which side of the head he 
hears it better. It is consequently a step toward an objective 
test, if not one itself, if the distinction which we ask the patient 
to make is one so easily made that even an ignorant person can 
make it. It is, I believe, perfectly easy for even a stupid per- 
son to determine which of two sounds is the louder if there be 
any appreciable difference between them. This is the whole 
problem to be solved in determining the difference between 
conduction by air and by bone. This subject will be more 
fully discussed in the chapter devoted to diseases of the in- 



54 AERIAL AND BONE CONDUCTION. 

ternal ear. Here it will be sufficient to indicate the method of 
testing. 

A tuning-fork " C 2 " (according to Helmholtz C 2 =528 vibra- 
tions) is heard better by persons with normal hearing when held 
while vibrating in front of the entrance to the external auditory 
canal — that is, it is heard louder. It is also heard longer. This 
is also true of other forks, but for the sake of clearness the re- 
marks here made are confined to the C 2 tuning-fork. At my 
request, Dr. J. B. Emerson, Assistant Surgeon to the Manhattan 
Eye and Ear Hospital, undertook some experiments, which show 
these statements to be correct. 1 

Starting from such observations upon healthy ear, we find 
that in disease of the external or middle ear the intensity with 
which the tuning-fork is heard through the bones is increased. 
In other words, the natural relations between conduction through 
the air and through the bones is disturbed. The bone conduction 
is better than the aerial. It has also been ascertained by many 




Fig. 1.— Tuning-fork. 

examinations that the diagnosis of disease of the middle or ex- 
ternal ear may always be made when the bone conduction is 
increased in intensity and relatively in duration. On the other 
hand, in a case of impaired hearing with a loss of bone conduc- 
tion, while the conduction through the air — aerial conduction — 
remains, we know that we are dealing with an affection of the 
labyrinth or acoustic nerve. We may formulate the propositions 
as follows : 

I. If the hearing be impaired, and we find the aerial conduc- 
tion better than that through bone, we are dealing with disease 
of some part of the acoustic nerve, which may be either pri- 
mary or secondary to disease of the middle ear. 

II. If the conduction through the bone be intensified and last 
longer in time than the aerial conduction, our case is one of dis- 
ease of the middle or external ear. Of course, if the case be one 
of impacted cerumen or other disease of the external ear, it is at 
once diagnosticated by an examination, and the test by the tun- 
ing-fork is practically useless, but it becomes very valuable in 
cases where we are in doubt as to whether disease of the middle 

1 Archives of Otology, vol. xv. , No. 1. 



AERIAL AND BONE CONDUCTION. 56 

or internal ear exists, if, as I believe, after much experience, it 
be one that can be depended upon. The method of making the 
test is extremely simple. The tuning-fork is placed in vibration 
by being struck on the knee of the examiner. It is then held in 
front of the meatus to test the vibrations through the air, and 
is again set in vibration and its handle placed on the mastoid 
process about in its centre to test the conduction by bone. 

In testing the duration of the conduction by air (aerial con- 
duction) or by bone, a stop-watch is essential for accuracy. The 
patient indicates the moment he ceases to hear the vibrations 
by lifting the hand. I am well aware of the criticisms made 
against this method of examination, that it is entirely subjec- 
tive, that it leaves too much to the patient's intelligence and 
truthfulness, and so forth. To these and similar objections I 
can only answer that those who give this method of using the 
tuning-fork a fair trial will, I am sure, find that it is an ex- 
tremely valuable test. In my opinion the test by aerial and 
bone conduction will, if tried, supersede all the methods of ex- 
amination by the tuning-fork as yet known. 

The tuning-fOrk is heard better through the bone in disease 
of the middle ear because of the increased resonating capacity 
of these parts when diseased by increase of tissue. When, on 
the other hand, there is disease of the acoustic nerve, the sound 
is heard most distinctly and longer when it passes through the 
best channel — that is, through the external auditory canal, the 
tympanic cavity, and the fenestra ovalis. 

When an affection of the middle ear exists which cannot be 
detected by the watch or by conversation, although said to exist 
by the patient, it will be found that the tuning-fork will con- 
firm the patient's statements that one ear "is not right ;" that 
is, the bone conduction will be longer and more intense than 
the aerial ; and a thorough inflation will often restore the nor- 
mal relations. The objections that have been made as to the 
value of the tuning-fork as a means of assisting in a differential 
diagnosis, are chiefly against the old method of determining on 
which side the tuning-fork is heard better. Yet even when used 
in this way it is valuable, although as I trust, it is soon to be 
superseded by the simple tests of the intensity and duration of 
aerial and bone conduction. 

According to Politzer, 1 E. H. Weber was the first to show 
the facts that have been stated with regard to the increase in 
intensity of the sound of a tuning-fork on the side of the meatus 
that is closed by the finger. Mach, quoted by Politzer. ex- 
plained this fact by the theory that the reflections of the waves 

1 Reprint from Wiener Medizinisehen Woehensehrift. 



56 THEORY OF TEST BY TLTNTNG-FORK. 

of sound from the ear was prevented by this closure of the 
auditory canal. Politzer concludes, as the result of experi- 
ments, which may be found in detail in the first volume of the 
" Archiv fur Qhrenheilkunde," that the increased perception of 
sound that is felt in one ear depends upon two causes : 

1. The waves of sound that have been carried from the bones 
of the skull to the air of the external auditory canal are reflected 
back on the membrana tympani and ossicula auditus. 

2. In accordance with Mach's theory, the passing out of the 
waves of sound which have reached the labyrinth and cavity of 
the tympanum, through the bones of the head, 1 is prevented by 
the obstacle they meet in the closed ear. 

It will thus be seen that Mach and Politzer explain the phe- 
nomenon of increased perception of sounds conveyed through 
the skull, in an ear whose peripheric portions are obstructed by 
disease, or by some mechanical cause, entirely by the theories 
that the loss of sound is prevented by the obstruction to its re- 
flection from the auditory canal, and that the force of the waves 
is also intensified by their being thrown back upon the nerve. 

Even if we do not now employ the tuning-fork by determin- 
ing on which side of the head it is heard better, the explanations 
as to the interesting phenomena revealed by such a test are not 
without value, and they are accordingly given. If, in a decided 
case of catarrh of the middle ear, the tuning-fork is heard better 
on the normal side, we must conclude that there is some lesion 
of the labyrinth — perhaps as Politzer 2 and Schwartze suggest, 
"a fluxion toward the labyrinth with serous exudation in the 
nerve structure." In cases of this kind, as the pressure upon 
the labyrinth is removed by a decrease of the catarrh of the 
middle ear, the tuning-fork will be heard better on the affected 
side. 

Politzer 3 explains the fact that in some cases of perforation 
of the membrana tympani, the tuning-fork is heard better on 
the affected side by two reasons : 

1. The mobility of the ossicula auditus, by which the passage 
outward of the waves of sound that have once reached the laby- 
rinth is retarded, is lessened. 

2. By the perforation of the drum-head, the cavity of the 
tympanum and auditory canal are converted into one space, 
and a greater resonance from the larger air-chamber is pro- 
duced, which acts upon the fenestroe ovalis and rotunda, and 
increases the intensity of the perceptive power of the labyrinth. 

1 Archiv fur Ohrenlieilkunde, B. I., p. 321, 1868. Tolitzer, loc. cit. 

2 Loc. cit. , p. 5. 3 Loc. cit. , p. 12. 



BLAKE S TUNING-FORK. 



57 



The tuning-fork used by Politzer in his experiments and in 
his practice corresponds to the second C in the base, vibrating 
512 times in the second. On striking it, we notice particularly 
two distinct tones — one the ground tone or dominant, the other 
the upper tone or musical fifth ; either one or the other pre- 
dominates, according to the density of the substance against 
which the tuning-fork is struck. In employing it for diagnosis, 
the predominance of the upper tone is often very confusing to 
the patient, and the cause of error. 

In order to get the pure dominant, it is only necessary to 
affix a pair of metal clamps to the ends of the branches ; this is 
done by means of small screws. If the tuning-fork is now 
struck even with a hard substance, only the dominant is percep- 
tible. Dr. Schaar, 1 of Vienna, diminishes the intensity of the 
upper tone by gentle pressure upon the lower por- 
tion of the branches. The value of the tuning-fork 
in testing the perception of different musical tones 
has been much increased by the discovery that, 
by fixing the clamps at different points upon the 
branches, it is possible to obtain all the tones and 
semitones up to an octave above the musical 
fourth of the dominant tone of the tuning-fork. — 
(Politzer.) 

Dr. Blake, 2 who has written a good digest of 
this subject, says that " Itard used a bell which 
was struck by a pendulum, the force of the blow 
being determined by the space through which the 
pendulum passed before striking ; in this way the 
difficulty as to control of the intensity of the sound 
was overcome, but the tone remained the same." 
Following this idea, Dr. B. caused to be constructed 
the tuning-fork as represented in the accompany- 
ing woodcut (one-third size), that is, the common 
instrument with the clamps as used by Dr. Polit- 
zer, but with the addition of a hammer, the head 
of steel, one face being covered with soft rubber. 
" Lucse proposed the, use of a hammer faced with 
some elastic material for striking the tuning-fork. 
The handle of the hammer is a steel spring, sliding in a bar af- 
fixed to the stem of the fork, and fastened in place by a small set 
screw. By using either the steel or rubber face of the hammer, 
either the upper or lower tone will be rendered most prominent. 




Ft;. -2.— Blake's 
Tuning-fork. 



1 Blake : Reprint from Boston Medical and Surgical Journal, p. 3. 

2 Blake, loc. cit. 



58 ENTOTIC USE OF SPEAKING-TUBE. 



j* 



By affixing the clamps as Politzer directs, we obtain the variety 
of tone, and by the distance to which the hammer is sprung can 
regulate their intensity. The adjustment is simple, and obviates 
the necessity of employing any other musical instrument." 

In cases of disease of the auditory nerve, it is often of in- 
terest to test the capacity of the patient for hearing high or low 
tones. For this purpose I use a piano, connecting the ear of the 
patient to the keys by means of a flexible stethoscope. Politzer l 
uses an harmonium, in the casing of which is an opening, for 
the insertion of the auscultation tube. 

Dr. Bing makes what he terms an entotic application of the 
hearing-trumpet as a means of diagnosis. In practising Bing's 
method, words are spoken into the mouth of a hearing-trumpet, 
the other end of which is directly connected with the cavity of 
the tympanum by being inserted into the nozzle of a Eusta- 
chian catheter, whose extremity lies in the Eustachian tube. 
The waves of sound pass through the hearing-trumpet and 
catheter directly to the base of the stapes bone, and are thus 
transmitted to the terminal filaments of the acoustic nerve. In 
a case in which speech cannot be at all understood through a 
hearing-trumpet, but is heard by its application to the interior 
of the tympanum, we may conclude that the hindrance to the 
conduction of sound is in the malleus or incus, while the mobility 
of the base of the stapes is not impaired. 2 

For a full account of Lucae's interference otoscope or apparatus see previous edi- 
tions of this work. I have omitted it in this edition, since it seems to me that all the 
tests by the tuning-fork except the simple one have become unnecessary. 

MALINGERING. 

In countries where liability to military service is universal, 
there are many malingerers, who claim to be dull of hearing in 
one or both ears. Next in frequency, it is claimed that there is 
absolute deafness of one ear only. It is so difficult to maintain 
for any length of time a false assertion of absolute deafness of 
both ears, that it is seldom attempted. The only malingerers that 
I have seen in our country since the close of the civil war, have 
been found among the applicants for the pensions that our Gov- 
ernment gives with such liberality to those who were in any 
way disabled while in the national service. Dr. David Coggin's 3 
method of testing a patient who states that he is deaf of one 

1 Text-book, p. 167. 

2 Politzer : Lehrbuch, S. 215. Translation, p. 186. 

3 Archives of Otology, Vol. viii., p. 177. 



coggin's test. 59 

ear is simple and valuable. He uses a Camman's bin-aural 
stethoscope. He plugs the right metal socket with a wooden 
stopper if the patient claims to be deaf of the left ear. On using 
the stethoscope in this manner for hearing speech, a person with 
good hearing power will find that he cannot distinguish it with 
the right ear. The person who claimed to be deaf of the left 
ear, was first tested while the tube of the right arm was plugged, 
and it was found that he could hear a whisper in the thoracic 
cup, which served as a mouth-piece. The tube containing the 
plug was then removed, and the tragus was firmly pressed 
against the meatus, so as to completely close it. Then the tube 
was applied to the left ear, as before ; the patient positively de- 
nied that he could hear what Dr. Coggin said to him. He knew 
that the tube through which he supposed he heard before was 
no longer in the right ear. As has been said, simulation of im- 
pairment of hearing on both sides is very difficult to detect. 
Such a person should be kept under observation for some few 
days, and repeated examinations made as the ingenuity of the 
surgeon may suggest them. 

EXAMINATION OF AUDITORY CANAL AND MEMBRANA TYMPANI. 

The next step after noting the hearing power in the examina- 
tion of our imaginary patient, is the exploration of the auditory 
canal and the membranee tympani. 




Fig. 8. — Angular Forceps. 

It is, of course, implied in this that an affection of the auricle 
needs no special assistance for examination. 

For the purpose of examining the external auditory canal 
three instruments may be necessary : a pair of angular forceps. 
an aural speculum, and a concave mirror or reflector. The first 
is of use to remove any temporary obstructions which may pre- 
vent a view ; the second dilates the canal ; and the third throws 
the light into it. 



60 SPECULA. 

According to Wilde, 1 Dr. Newbourg, in a memoir published 
at Brussels in 1827, recommended an instrument which is the 
origin of all the tubular ear specula now in use. It was a slender 
horn tube, four inches long, with a bell-shaped outer orifice. 
Subsequently this instrument, which was much too long, was 
improved by shortening it, by Dr. Ignaz Gruber, of Vienna, and 
generally introduced to the profession by Sir William Wilde in 
1844. After a fair trial of the bi-valvular instrument of Kramer, 
and the funnel-shaped one of Toynbee, I now use the conical 
speculum, either that of Wilde, Troltsch, or Gruber. I do not 
think that any one of these has any great advantage over the 
others. The practitioner will do very well with any one of them. 
Too much stress is sometimes laid on a little change in shape. 
I prefer that the interior surface of the speculum be brilliant, 
and not black, as those of Gruber are sometimes made. 

Those who consider that there is an advantage in a funnel- 
shaped instrument will find the one here figured preferable to 




Fig. 4. — Gruber 1 s Speculum. 

Toynbee's, because the transition from the wide orifice, which 
dilates the cartilaginous part of the canal to its fullest extent, 
to the narrower, which exposes the osseous portion, is gradual, 
and thus prevents the reflection of many rays at this point. 

The speculum for ordinary use should be made of coin silver 
or it should be nickel-plated. For the purpose of applying acids 
or caustics, one of hard rubber, porcelain, or glass is to be pre- 
ferred. The instrument is warmed by the hand before being 
used, and then inserted gently and slowly into the meatus with 
the right hand, the auricle being lifted up with the left, and 
the speculum held in position by the thumb and index finger 
of the same hand. It will thus be kept under complete control, 
and the examiner will be able to turn it so as to successively 
view the different parts of the whole surface of the membrana 
tympani, and at the same time to thoroughly straighten the 
canal by pushing up its upper wall. 

It is very important that the speculum be held properly, for 
I have seen many a student, for the want of knowledge of this 

1 Treatise on Diseases of the Ear. English edition, p. 60. 



METHOD OF USING SPECULUM. 



61 



simple manipulation, labor for a long time without getting any 
view of the membrane, while the instrument was resting on 
some portion of the projecting wall of the canal. A very con- 
siderable amount of pain may be caused by the rude introduc- 
tion of the speculum. I would advise each practitioner to allow 
one to be introduced into his own auditory canal, before he be- 
gins to use the instrument upon his patients. 

Having thus dilated the canal, the light may be thrown into 
it by means of the otoscope or reflector of Troltsch, which is a 
concave mirror of about three inches in diameter, having a focal 




Fig. 5.— Method of Holding the Speculum in Position. 



distance of about six inches. Ordinary daylight is the best 
source of illumination for this mirror, although sunlight, lamp- 
light, gaslight, that of a candle, or the reflection from a light- 
colored wall, may each be made available in this method of ex- 
amining the outer parts of the ear. This is a very simple process. 
although many make a difficult one of it. If we but use the skill 
we acquired in our juvenile days, in throwing a dazzling light 
upon a desired object by means of a bit of broken mirror, it will 
serve us in good stead here. The mirror is held very lightly in 



62 METHOD OF EXAMINING MEMBRAXA TYMPANI. 

the hand, and the light is condensed upon any desired part by a 
very slight movement. 

It is now almost universally conceded by the profession that 
this method is altogether the best that has yet been suggested 
for the examination of the membrana tympani. It was first 
introduced to the profession at large by Professor Anton Von 
Troltsch, in 1855, without previous knowledge that it had been 
suggested by others, although Dr. Hoffman, of Westphalia, had 
previously, in 1841, used an ordinary shaving mirror with a cen- 
tral opening for the examination of the ear. Professor Edward 
Jaeger, in his work on "Cataract and Cataract Operations/' 
published in 1853, suggests that his ophthalmoscope may be 
used with the concave mirror of four inches focal distance, for 




Fig. 6. — Method of Examining the Auditory Canal and Membrana Tympani. (A handle 
to the otoscope other than that formed by the head-band is not necessary. It will be found 
much more convenient to make the head-band serve a double purpose.) 

the examination of the external auditory canal. I have also 
been informed by numerous practitioners that they have often 
used the ophthalmoscopic mirror for examining the ear ; but in 
spite of all these statements and the fact that Frank, 1 in his 
work on the ear, gives a sketch of Hoffman's otoscope, the 
credit of the introduction into general use of the concave mirror 
for the examination of the ear as certainly belongs to Troltsch, 
as the invention of the ophthalmoscope to Heinrich Helmholtz. 
It is somewhat surprising, however, that after the description 
which Frank gives in his text-book of Hoffman's method, and 
the drawing which he furnishes of the mirror, no attention was 

1 Practische Anleitung zur Erkentniss der Olirenheilkmide, p. 49. 



TROLTSCIFS OTOSCOPE. 



63 



paid to the subject until Troltsch revived it, without knowing 
of Hoffman's apparatus. 

I introduced the use of the aural mirror, or otoscope as it 
should be called, into the practice of the New York Eye and 
Ear Infirmary, in 1863, where it soon superseded 
all other methods, and whence it has been very gen- 
erally adopted in the United States. 

It may be safely said that the adoption of this 
simple method of examination, has done more for 
the scientific and practical study of aural disease 
than any previous suggestion in this department. 
It has placed within the hands of every practitioner 
a method by which he may, in a few minutes, learn 
to examine a membrane which not a few physicians 
have never seen on the living subject. 

I deem it unnecessary to describe the numerous 
methods which preceded that of Troltsch, since they 
are fast becoming obsolete, and their description 
belongs rather to the history of otology than to a 
practical treatise. Even the method of examina- 
tion by means of the direct rays of the sun, which held out so 
long in the hands of some practitioners, has at last given way 
to the use of the mirror and ordinary daylight. 

It is sometimes convenient for the examiner and the patient to 
sit during the examination of the membrana tympani, and some- 
times both may stand, or, as I usually examine, the patient may 




Fig. 7. —Collin' 
Lamp. 




Fig. 8.— Forehead Band. 



sit in a revolving chair, while the surgeon stands. The position 
of the patient will not be an important matter, so long as a good 
illumination is thrown into the canal. A forehead band is essen- 
tial in making applications to the ear, and it is often convenient 
at other times. I cannot see any advantage in the various com- 
plicated and expensive bands with ball-and-socket joints, but 1 
use a simple screw attachment by which the mirror is fastened 



64 BINOCULAK OTOSCOPY. 

to the head-band. I prefer a head-band of elastic material, such 
as india-rubber webbed cloth. 

Dr. Di Rossi, 1 in a paper on " Binocular Otoscopy," proposes 
the use of a microscopic object-glass set at an angle of 70° in a 
spectacle frame, as a simple and efficient binocular otoscope. 2 

Dr. Di Rossi's first instrument 3 consisted of an arrangement 
of prisms behind a concave mirror. The prisms are plane, one 
of 90°, the other of 10°. The diameter of the concave mirror is 7 
centimetres. Its focal distance is 16 centimetres. 

The central opening in the mirror is of an elliptical shape. 
The instrument differs from the binocular ophthalmoscope of 
Dr. Giraud Teulon in the following respects : 

1. The mirror is much larger, inasmuch as ordinary daylight 
is used as the source of illumination. 

2. The focal distance is less. 

3. The prisms are of a higher degree. 

I think the advantages of binocular vision in examining the 
ear, are not sufficient to atone for the loss of simplicity and 
cheapness in the instrument used for examination, that occurs 
when the binocular otoscope is substituted for Troltsch's monoc- 
ular concave mirror. A little practice enables the surgeon to 
judge with sufficient accuracy as to the depth of objects in the 
canal or upon the drum-head, or beyond it, upon which he is 
operating ; for it is only in operating, for example, in punctur- 
ing the membrana tympani, that I have ever felt any difficulty 
in judging of the depth of the surface which it was desired to 
touch. 

I seldom look through the opening in the mirror, but rather 
over the rim of it. The presbyope and hypermetrope will need 
his reading glasses, in order to make an examination of minute 
points. A clip containing the appropriate convex lens may be 
made for those who look through the hole in the mirror. Those 
who do not, will be obliged to employ their glasses used for read- 
ing, in order to get an accurate view of some of the details of the 
drum-head, ossicles, or the tympanic cavity. A lens may be in- 
serted in the speculum, as suggested by Dr. Loring. 4 

Mr. Edward S. Ritchie, of Boston, at the suggestion of Dr. 
Clarence J. Blake, 5 has made an instrument which is designed to 
overcome the disadvantages attending the exclusion of one eye 
from the visual act in operating upon the membrana tympani : 

1 Monatsschrift fur Olirenheilkunde, Jahrgang VI., No. 7. 
- Mr. H. W. Hunter, optician, will furnish the apparatus. 

3 Monatsschrift fur Olirenheilkunde, No. 12, 1869. 

4 Verbal Communication, N. Y. Ophthalmological Society. 

5 Late Contributions to Aural Surgery. Boston, 1870. 




OPERATING OTOSCOPE. 65 

" It consists of a hard rubber speculum (Politzer's) of the 
largest size, fitted with a metallic rim, to which is attached a 
revolving prism and an arm, bearing at its outer end a lens of 
about an inch focus ; this arm is movable, but sufficiently firm 
to remain fixed at any angle at which it 
is placed. The prism is just within the 
focal distance of the lens, and its inci- 
dent face is armed with a small metal 
shield, having an opening in the centre 
corresponding in its short diameter to 
the diameter of the pencil of light falling 
upon it from the lens. 

"The advantage of a prism over a 
mirror or other reflecting surface is, 
that we have almost total reflection ; 
and but little of the light concentrated 
upon the prism by the lens is lost. 

r , , T r . . J . . . . Fig. 9.— Blake's Operating Oto- 

" In operating, an assistant is re- scope . 

quired to draw the auricle upward and 

backward, and keep the speculum in position, with the pencil 
of light upon the opening in the shield of the prism. It is not 
claimed for this instrument that it at all supersedes the head 
mirror of Troltsch, but it is certainly of great advantage in the 
more complicated operations, where a steady and uniform illu- 
mination is indispensable. The instrument, as a whole, weighs 
only about one hundred and fifty grains, and can be made much 
lighter ; so that when once firmly inserted in the meatus, it re- 
mains in position, and there is no necessity for holding it nor 
fear of its slipping out of place during the operation." 

The practitioner will often be obliged to examine the ear and 
pharynx of a patient who is too ill to get up from the bed. The 
light from a candle or of Collin's lamp then becomes a very con- 
venient and ample means of illumination. The finest changes 
on a membrana tympani and in the auditory canal may be ob- 
served by the aid of the otoscope and such a light. 

EXAMINATION OF THE PHARYNX AND EUSTACHIAN TUBES. 

After having heard the patient's history, and having ascer- 
tained the amount of hearing, we may proceed to the examina- 
tion of the pharynx and nares, and mouths of the Eustachian 
tubes. Although the profession has been a long time in coming 
to an appreciation of the fact, it is now generally conceded thai 
the starting-point of a large percentage of aural cases is in these 
parts. 

5 



m 



PHARYNX AND EUSTACHIAN TUBES. 



The pharynx is best examined by turning the patient's face 
to an open window, and holding the tongue by means of Turck's, 

or a simple hinge speculum. Turck's 
instrument is to be preferred to others, 
because the hand of the examiner does 
not obscure the view in its use. I 
often, however, use a reflector and ordi- 
nary daylight for an inspection of the 
pharynx, and it has some advantages 
over a direct illumination. 
Fig. 10. -Hinge Speculum. Some surgeons prefer to use artificial 

light in examining the pharynx as well as other parts of the 
body, but I much prefer ordinary daylight for all examinations, 
when it is possible to use it, to that from any artificial source, 
or to the direct rays of the sun, since it seems to me that the 
natural hues are thus best observed. In the evening, of course, 






Fig. 11. — Turck's Speculum. 

artificial light must be used. A reflector should then be em- 
ployed. It is well to have the reflector attached to a forehead 
band, as in the practice of rhinoscopy or pharyngoscopy, which 
will be immediately described ; but I may defer any description 
of what to observe on examining the fauces and pharynx until 
we come to speak of pharyngeal disease. 



RHINOSCOPY. 



Rhinoscopy, as a practical method of examining the posterior 
nares, was suggested by Sir William Wilde in his treatise on 
"Aural Surgery," having previously been spoken of by Bozzini, 



RHINOSCOPY. 67 

as a possible method of examining the parts behind the hanging 
palate, in a book published in Weimar in 1807. x 

Professor Czermak, of Prague, following up Turck's investi- 
gations on the larynx, was the first to actually introduce rhino- 
scopy into anything like general use ; while Dr. Semeleder, 
Surgeon to the Gumpendorf Hospital in Vienna, and afterward 
Surgeon to the Archduke Maximilian, while in Mexico, gave us 
the first full account of what was to be observed by this means, 
with some interesting cases. Voltolini, of Breslau, has also 
added much to our knowledge of the value of this means of 
diagnosis. 

It is by no means necessary that every aural patient should 
be examined with the rhinoscope, nor will the most accom- 
plished manipulator be able to see the mouth of the Eustachian 
tubes in every case ; but every one who attempts to treat the 
disease of the organ of hearing will find his diagnosis very often 
facilitated by an inspection of these parts ; for example, when 
any unusual difficulty is experienced in entering the mouth of 
the Eustachian tube. 

For the practice of rhinoscopy we need a lamp, or other 
source of artificial illumination, a small mirror, a tongue spat- 
ula, and a concave mirror that may be attached to a forehead 
band or placed on Semeleder's spectacle frame. Any brightly 
burning lamp, or a good Argand gas-burner, will answer as a 
source of illumination. 

Various kinds of costly apparatus for the purpose of con- 
densing the light have been suggested and employed. If the 
surgeon be not satisfied with an ordinary lamp, perhaps the 
apparatus of Tobold will be found the best. In some in- 
stances, although not always, an instrument for holding back 
the uvula is required. Various appliances have been suggest- 
ed for this purpose, nooses, hooks, spatulas, and so on, for any 
of which a surgeon of ordinary tact will find a substitute when 
wanted. 

It is above all things requisite, that the patient should be 
tractable, and this tractability is perhaps more common than 
many surgeons imagine. Those who precede all their manipu- 
lations by an appeal to their patients to be very quiet, to be sure 
not to stir, not to mind a little pain, etc., and who at the same 
time make a great show of instruments, will generally have in- 
tractable and timid patients ; but he who goes quietly to work, 
will find few patients that will not submit with more or less 

1 Laryngoscopy and Rhinoscopy. By F. Semeleder. Translated by Dr. E. T. Cas- 
well, 18(30. 



68 KHINOSCOPY. 

patience to all such manipulations as are required in rhinoscopy^ 
the use of the Eustachian catheter, and the like. 

The patient being seated in front of the examiner, with a 
good light at one side, the mouth is well opened, and the tongue 
held by means of the depressor mentioned above. The surgeon 
should be careful in placing the tongue depressor, so that he 
may not cause undue pressure, which will produce gagging, and 
prevent all further manipulations. The light is then turned 
upon the pharynx by the head mirror, so that it is accurately 
focused, when the parts will be well illuminated. 

Having secured a good view of the pharynx, uvula, and ton- 
sils, the throat mirror is to be introduced. This instrument is 
first warmed by holding it for an instant over the flame of the 
lamp ; its heat is then tested by placing it on the back of the 
hand, after which it is gently and quickly introduced, with its 





Fig. 12. — Anterior Nares Speculum. Fig. 13. — Goodwillie's Nasal Speculum. 

reflecting face upward, into the space between the soft palate 
and cavity of the posterior pharyngeal wall. There are some 
patients, however, in whom it will be impossible to make a 
rhinoscopic examination, on account of the small space between 
the uvula and posterior wall of the pharynx. A very few, also, 
have such irritable throats as also to render such an examina- 
tion impracticable. 

The examination of the nostrils anteriorly — anterior rhinos- 
copy, as it is called by Cohen n — is often an important part of 
the examination of a case of aural disease. 

It is very often sufficient to place the patient in front of a 
good light, and open the nares by pressing upon the tip of the 
nose. For a thorough examination the anterior nares speculum 
above represented, or that of Dr. Goodwillie, are very useful. 

Zaufal, of Prague, has of late years laid great stress upon 

1 Diseases of the Throat, p. 75. 



69 

anterior rhinoscopy. He has devised a set of nasal specula for 
this method of examination, and he has contributed largely to 
our knowledge of the morbid appearances of the nasal cavities. 
A little experience must be had with these specula, before the 
surgeon will be willing to trust himself to deductions from what 
he may see. 

Zaufal's specula are long tubes of various sizes adapted to 
the inferior meatus of the nose, with a funnel-like extremity 
through which the light is thrown. When Dr. Weir, of this 
city, was an aural surgeon to one of our infirmaries, he used the 
tube of the endoscope for the same purpose of obtaining an an- 
terior view of the mouth of the Eustachian tubes, but Zauf al has 
made much greater publicity of the results of his examinations 
by this method — and probably never knew of Weir's work in the 
same direction. 



EXAMINATION OF THE EUSTACHIAN TUBE. 

We may now turn, as the next step in our examination of a 
case of supposed aural disease, to the investigation of the con- 
dition of the Eustachian tube and cavity of the tympanum. 
The means of this examination may be classified as follows : 
I. The Eustachian catheter. 
II. Politzer's method. 

III. Valsalva's method. 

IV. Eustachian bougies. 

From the date of the promulgation of the use of the Eus- 
tachian catheter by the postmaster of Versailles, Guyot, until 
Toynbee's time, the views of the profession as regards the use 
of this instrument have varied exceedingly. At one time it was 
almost utterly rejected by the greater number of respectable 
practitioners, and at another time has been considered by them 
as a panacea in the treatment of aural disease. The text-books 
of Wilde and Toynbee, which attached very little importance to 
the use of the Eustachian catheter, and which bear intrinsic 
evidence that the authors did not choose to be very familiar 
with the details of the proper employment of the instrument. 
probably did more than anything else to cause the profession in 
our own country to settle down, until a few years since, into the 
belief that the Eustachian catheter was always a useless and 
sometimes a dangerous instrument. I well remember the dis- 
couraging response of a prominent American practitioner, who 
had then had large experience in aural disease, to my state- 
ment, at the beginning of my active professional life, that I pro- 
posed to use the Eustachian catheter in the treatment of diseases 



ro 



EUSTACHIAN CATHETER. 




of the ear, that he was glad to say that he never had used the 
instrument, and this was the common sentiment among our re- 
spectable practitioners until the publication of an English trans- 
lation of Troltsch's work on the ear. In respect 
to the change in sentiment in this regard, I only 
need to say, that nearly every American surgeon 
who now treats aural disease, attaches much 
importance to the use of this instrument. 

We have now to speak of the Eustachian 
catheter as a means of diagnosis. The material 
of which the instrument should be made may be 
either hard rubber or alloyed silver. For the 
injection of warm vapors the hard rubber in- 
strument is the only one to be used, because the 
heat will very soon make it impossible for a pa- 
tient to bear the metal instrument in the nostril. 
For myself, I use the hard rubber instrument for 
all purposes. 

In the method of introduction, we proceed as 
did Archibald Cleland, an English surgeon, who, 
after Guyot, did the most to demonstrate the 
utility of entering the mouth of the Eustachian 
tube with an instrument, and we pass the cathe- 
ter through the nostril. It is very difficult to 
imagine how the Versailles layman succeeded in 
introducing an instrument into the tube, through 
the mouth. He certainly did not use a catheter 
such as we now employ, and which is represented 
on this page. This instrument is a delicate 
tube of about six inches in length, with a slight 
curve at its extremity. A long and flexible 
catheter might, it is true, be passed behind the 
soft palate into or opposite the mouth of the 
tube, and this is the operation which Guyot 
demonstrated to the Paris Academicians, and 
which, by removing mucus from about the trum- 
pet-shaped pharyngeal extremity of the canal, 
relieved his impairment of hearing. 1 

The various steps in the operation of intro- 
ducing the Eustachian catheter are as follows : 
1 . Let the patient be seated on a chair, with 
a little higher back than usual, so that the head may be sup- 
ported. If the patient be a child or a very timid subject, it may 




Fig. 14. — Eusta- 
chian Catheters (ac- 
tual size). 



For a fuller account of Guyot's operation, see Introductory Chapter. 



EUSTACHIAN CATHETER. 



71 



rest its head against a table or wall, or what is better, be sup- 
ported by an adult. 

I seldom use the Eustachian catheter in young children ; for them I almost 
exclusively use Politzer's method of inflating the middle ear. 

2. Let the patient blow his nose, so as to moisten the passage 
and remove any collections of mucus, while the surgeon takes 
the catheter, thoroughly cleansed and warmed, and forces air 
through it in order to be sure that it is permeable. 

3. The operator, standing a little to one side, draws down the 
upper lip with the left hand, and with the thumb and finger of 




Fig. 15. — Introduction of Eustachian Catheter. 

his right hand lightly holds the catheter close to the funnel- 
shaped end, nearly in a vertical position, so that the guide or 
projection at the side of the funnel-shaped extremity looks 
directly downward, until the catheter has entered the meatus, 
when it is quickly turned to an approach to the horizontal 
position, when the beak will rest on the floor of the nasal 
meatus, close to the septum, with its convexity upward. 

4. The catheter is then to be slid or insinuated backward with 
a gentle motion, keeping it as close as possible to the floor of the 
meatus, gradually elevating the handle until the instrument be- 
comes perfectly horizontal and the beak rests upon the posterior 
wall of the pharynx. 



72 EUSTACHIAN CATHETEE. 

5. At this point the funnel-shaped end of the catheter in the 
hand of the operator is to be raised a little above the horizontal 
line and at the same time withdrawn a little. 

6. Turn the catheter about a quarter on its axis, from within 
outward. This motion lifts the beak of the instrument into the 
mouth of the Eustachian tube. This latter movement is aided 
somewhat by the contraction of the soft palate, which performs 
a swallowing movement, raises itself, and lifts the beak of the 
instrument into the tube. Once in position the catheter should 




Fig. 16. — The Eustachian Catheter in Position. 

not cause the patient any inconvenience in speaking or swal- 
lowing, and the guide will lie at about an angle of twenty-five 
degrees with the tragus. 

The difficulties that are found in introducing the catheter, 
simple manipulation as it is, arise from two causes : 

First, the surgeon does not always hold the instrument in a 
vertical position (see Fig. 15) until he has got the beak well in 
the meatus. A failure to do this will often cause the instrument 
to pass between the inferior and middle turbinated bones, in- 
stead of along the floor of the meatus, which must be hugged in 
order that the instrument may get to the mouth of the tube. 

Second, the patient is apt to shut his eyes spasmodically and 
contract his facial muscles, and thus prevent the relaxation of 
the parts that is necessary during the manipulation. This diffi- 
culty is only to be overcome by persuading the patient to open 
his eyes and look about the room, which can be done if the sur- 



DIAGNOSTIC TUBE. 



73 



geon have a quiet, assuring manner. This difficulty usually 
passes away with the second or third use of the instrument, and 
sometimes it does not arise. 

Having introduced the catheter we may force air through it 
into the cavity of the tympanum, by means of an air-bag whose 
nozzle should fit accurately in the funnel-shaped 
extremity of the nasal instrument. Air may also 
be blown in from the lungs of the examiner through 
a slender bit of rubber tubing, the tips of which are 
placed in the opening of the catheter and the mouth 
of the examiner respectively. The use of the rub- 
ber-bag or syringe is to be preferred to the latter 
method, on the ground that it is not likely to offend 
the natural feelings of the patient, against the in- 
troduction of air from the lungs of the examiner. 

After air has been forced into the middle ear in 
this manner, the membrana tympani should again 
be examined by the surgeon, to determine if it has 
become injected, or if it has undergone any change 
in position ; that is to say, he should see whether 
has actually reached the cavity of the tympanum or not. 

I have caused an exact representation to be made of the size 
and curve of the Eustachian catheters used by me, for I was for 




Air- 



current 




Fig. 18.— Diagnostic Tube. 



a long time greatly annoyed by the difficulty which I often 
found in introducing instruments of a larger calibre and curve. 
I am constrained to believe that the catheter would be much 
more widely employed, were instruments of small calibre and 
curve generally figured in the text-books and sold in the shops. 

Most authorities recommend the use o( an instrument like 
the stethoscope, which is placed in the ear of the patient while 



74 politzer's method of inflation. 

the air is being driven through the tube, and they claim to be 
generally able to decide as to whether the air enters, by the 
sound communicated through the tube. I believe it will be 
found very difficult to distinguish sounds proceeding from 
the pharyngeal mouth of the tube from those produced in the 
cavity of the tympanum, and I do not, therefore, attach that 
importance to the use of the stethoscope in this manner, that 
has been usually ascribed to it ; but I rely more upon the ap- 
pearances of the membrane of the tympanum after the air has 
been forced in, with some attention also to the sensations of 
the patient, as to where the air is felt, than upon the use of the 
diagnostic tube. 

I very rarely make use of the instrument. It was formerly 
called the otoscope, a manifestly improper name, as Kramer 
said. The mirror for examining the canal and membrana tym- 
pani is the only otoscope. 

POLITZER'S METHOD OF INFLATING THE EAR. 

The next means of examining the condition of the Eusta- 
chian tube and cavity of the tympanum is named, from the 
physician who suggested it, Politzer's method. It is a means of 
diagnosis and treatment of very great value, and we owe very 
much to Professor Adam Politzer, of Vienna, for this method of 
sending air into the middle ear. 

As is very well known, in the action of swallowing, the 
uvula rests upon the pharyngeal wall so as to shut off the upper 
from the lower pharyngeal space ; so that persons affected with 
cleft palate, who cannot thus separate these spaces, are greatly 
inconvenienced by the passage of solids and fluids upward to 
the posterior nares. It was long ago shown by Toynbee, that the 
pharyngeal orifice of the Eustachian tube opened during the 
swallowing process. Politzer's method takes advantage of these 
physiological facts in the following way : the person to be ex- 
amined takes a little water in the mouth, while the surgeon 
places the nozzle of an air-bag into one of the nostrils, closes the 
other with his finger, and causes the patient to swallow the 
water at a given signal previously agreed upon, when he forces 
in the air by compressing the india-rubber bag. I usually say 
" now ; " upon which the patient swallows. 

In examining children, I use, as suggested by Mr. Hinton, 
a piece of rubber tubing, and force the air from my own lungs, 
on giving a signal by raising the hand. 

The effect of the air thus forced in upon the membrana tym- 
pani is often wonderful. A person who has become deaf to 



PULITZER S METHOD. 



73 



ordinary conversation, sometimes in an instant again hears 
,the familiar tones of human conversation, and feels himself in 
a new world. In such a case, mucus has obstructed the calibre 
of the tube, or the mobility of the ossicles has been interfered 
with. In the former case it is driven away by the current of 
air, which must of necessity go against the mouths of the tube, 
and will usually pass on into the middle ear. The patient's own 
testimony will usually, although not always, be conclusive as 
to whether the air entered the ear. The exceptional cases are 
those in which the Eustachian tube and the cavity of the tym- 
panum have become so nar- 
rowed by a hypertrophy and 
sclerosis of the lining mucous 
membrane that only a very 
narrow, feeble current can en- 
ter, or perhaps where atrophy 
of tissue has rendered it less 
sensitive than normal. We 
shall have need to dwell upon 
the uses of Politzer's method 
when we are discussing the af- 
fections of the middle ear, and 
I therefore content myself with 
this description of it, while we 
pass on to Valsalva's method of 
inflating the ear. 

A great many modifications 
of Politzer's methods of proced- 
ure, chiefly, however, as regards 
swallowing as a signal for the 
operator to compress the air- 
bag, have been made by various 
persons. Some of these bear 
evidence of the tendency of the evaporating substance). 
human mind to seek change, if only for the sake of change. 
Gruber causes his patients to say hie, hoc, instead of swallow- 
ing upon the signal. , He enters into a laborious argument 
to prove that his method is better than that of swallowing. One 
of his objections to Politzer's method is, that patients object 
to drinking from the glasses which he has near at hand. Dr. 
J. Oscroft Tansley, 1 of New York, proposed that patients, instead 
of swallowing, shall blow as if about to blow out a lighted 
candle. Both of these modifications of one minor part of Polit- 




FlG. 19.— Method of Using Politzer's Appa- 
ratus (with box for containing iodine or other 



1878. 



76 



tansley's MODIFICATION, 



zer's great invention, especially Tansley's, are of value in cer- 
tain cases. They are not more important as modifications of the 
method, than Hinton's use, in the case of children, of an india- 
rubber tube, through which air is forced from the lungs instead 
of from an air-bag. The late Dr. Peter Allen ' substituted a nasal 
pad, which is pressed against the opening into the nostrils, in- 
stead of into one of them. Two air-pads are mounted on a piece 
of covered copper wire. These can be brought close together 
or separated so as to stop up the openings into the nostrils. 

The pads are held in place by the metal which serves as a 
handle. There is a hole through each pad, and these holes com- 
municate with two short bits of rubber tubing joining into a 
single tube. The pipe of the air-bag used for inflating is inserted 
in this latter, and the apparatus appears as in the engraving. 

This instrument contains a very useful modification of Po- 
litzer's apparatus, and it is much preferred to the original by 




Fig. 20. — Dr. Allen's Nose Pads for Politzer's Apparatus. 

some surgeons. There is no advantage in the double bag such 
as is employed in the nebulizers, and which has also been pro- 
posed for Politzer's method. 

Tansley's method of blowing instead of swallowing was sug- 
gested to him, as he states, after practising Holt's method. Dr. 
E. E. Holt found that the air readily entered the tympana by 
closing the lips tightly and distending the mouth and cheeks 
easily with air, and then discharging the air-bag as in Politzer's 
method. He consequently caused the patients to undertake 
this manoeuvre instead of swallowing. I find the methods of 
Gruber and Tansley very useful in many cases, but in by far 
the most instances, I prefer to cause my patients to swallow on 
a given signal. 

I am told on reliable authority, that in one of the continental 
cities, rival teachers of otology lay great stress upon the impor- 



Treatise on the Ear, p. 97. 



valsalva's method. 77 

tant point as to whether the air-bag is pressed upon on its side 
or its distal end, when used for inflation. One teacher causes his 
pupils always to compress the bag on one side, while the other 
as strenuously insists that it can only be properly employed by 
compressing it from the distal end. 

VALSALVA'S METHOD. 

The distinguished anatomist Valsalva, who is well known to 
the profession by his treatise on the ear, suggested a means of 
inflating the membrana tympani, which has become so popular 
as to be used by nearly two-thirds of all the patients who come 
to physicians on account of their ears. It has been recom- 
mended by generations of medical men as a means of curing 
affections of the ear, or of determining if the Eustachian tube 
be open, or the drum-head broken. Universal as is its use, I re- 
gard it as almost a useless and not an entirely safe method. It 
consists essentially in forcing air into the ear, after a vigorous 
inspiration, the mouth and nostrils being closed. It will be ob- 
served that when the ear is inflated by this method, a very great 
use of the muscles of the chest is made ; and just in this lies the 
danger to the ear. This vigorous expansion of the chest causes 
a congestion of the ear which is sometimes more or less perma- 
nent, and materially harms the part by increasing the flow of 
blood to it. There is another objection to the frequent employ- 
ment of the Valsalvian method, or experiment, as it is some- 
times styled. It soon ceases to have its momentary effect of 
increasing the hearing distance, which it does by rendering the 
membrane of the drum tenser, and then the membrane becomes 
relaxed and flaccid, so that I have sometimes seen the mem- 
brana tympani of patients who have been in the daily and per- 
haps hourly habit of forcing air into the ears, flap to and fro 
like a valve, on the slightest movements of the nostrils. 

This latter objection, of course, applies to Politzers method 
if it be very frequently practised ; but as it must be done by 
means of an apparatus, patients are not so apt to take it into 
their own hands. I do not now advise the use of the Valsalvian 
method in the treatment of aural disease, and as a means of 
diagnosis it is, in most cases, vastly inferior to the use of the 
catheter or Politzer's method. 

BOUGIES. 

I may add a word about the last-named moans of examining 
the Eustachian tube, namely, bougies. Filiform catgut bougies 
may sometimes be employed with advantage in determining if 



78 BOUGIES. 

the non-entrance of air by the catheter or Politzer's method, be 
clue to a stricture ; but the need for their employment occurs 
only in a very limited number of cases, and when they are used 
great care and judgment are necessary. This subject will be 
fully discussed in the chapter on "Chronic Kon-suppurative In- 
flammation of the Middle Ear." The examination of the condi- 
tion of the drum-head and ossicles by Siegle's otoscope will also 
be discussed in the same place. 

It will be understood by the reader that very many cases of 
aural disease — for example, those of the external auditory canal 
— will not require the exhaustive examination that has just been 
detailed, yet many cases will require a systematic and complete 
observation, such as I have attempted to delineate, in order that 
an exact and consequently valuable diagnosis may be made. 
The time thus consumed is sometimes considerable, but it is not 
as great as those who simply read these descriptions will per- 
haps imagine. The details occupy more in description than in 
execution ; and their strict performance will of themselves in 
time make those who carry them out, good observers of the 
phenomena of disease. 



THE EXTERNAL EAR. 



CHAPTER III. 

ANATOMY OF THE AUKICLE AND THE EXTEKNAL AUDITORY 

CANAL. 

Auricle. — Etymology. — Anatomy of Muscles, Intrinsic and External. — Physiology. — 
Blood-vessels. — Nerves. — External Auditory Canal. — Anatomy of Curvature. — 
Ceruminous Glands. — Hairs in Canal. — Auditory Canal of Dog and Cat. — Relations 
of Canal to Parotid Gland, Inferior Maxilla, Mastoid Process, and Dura Mater. — 
Blood-vessels and Nerves. 



The auricle (auricula, external ear) is perhaps little more than 
an appendage to the human organ of hearing, although it is 
such an important part of the ear of certain animals. Its gen- 
eral shape is that of a funnel. Its frame work, or basis, is made 
up of flexible fibro-cartilage, and it is 
from one to two millimetres in thick- 
ness. The cartilage is of the variety 
known as reticular, and it is covered by 
perichondrium which contains many 
elastic fibres. These fibres pass into the 
substance of the cartilage, and form a 
network in the meshes of which small 
cartilage cells are embedded. From the 
time of Rufus of Ephesus the different 
parts of the auricle, which give it its 
beautiful and useful shape, have been 
named as follows : 

The edge that forms the outer border 
of the auricle is called the helix, from 
a Greek word, eAi£, anything twisted, 
eAto-o-w, to turn around. This ridge varies 
in breadth, and is more or less distinct 
in different individuals, according to 
the care that has been taken to preserve 
the shape of the ear. It begins at a 
point on the concave surface of the cartilage, called the spine or 
crest of the helix, spina sen crista kelicis. By following down 
the posterior border with the finger, it will be seen thai its tissue 
6 




Fig. 21.— The Auricle. 1, He- 
lix ; '., anti-helix ; 3, fossa helicia ; 
4, ooncha; 5, anti-tragus ; 6, tra- 
gus ; 7, lobe. 



82 



ANATOMY OF THE AURICLE. 



does not pass into the lobe of the ear, but that the latter is 
formed by the integument alone. 

Just beneath the helix is a fossa— fossa navicularis, or boat- 
like fossa — separating it from a second ridge-like border, the 
anti-helix. Just in front of the opening into the auditory canal 
the cartilage becomes thickened, and forms a projection or edge 
called the tragus (Latin for goat), because hairs usually grow 
upon this part, which were supposed by the ancients to give it a 
certain kind of resemblance to the beard of that animal. Just 




F.c. 



Fig. 22. — Profile View of the Skull, with the Skeleton or Cartilage of the Auricle, as well 
as that of the External Auditory Canal. The latter is exposed and drawn downward, cm. 
(after Henle). 1, Meatus auditorius externus ; 2, tttberculum articulare of the temporal 
bone; 3, mastoid process; t, transverse section of the zygomatic process; H y helix; J.. A., 
anti- helix ; F.t., fossa triangularis; S, scapha, or fossa navicularis; F.c, concha; C. h., 
cauda helicis ; A .t., anti -tragus ; T, tragus; ** *, fissures in the cartilage of the external 
auditory canal. 



opposite to this, across the mouth, or meatus, of the auditory 
canal, is a similar projection, called the anti-tragus. The great- 
est concavity of the auricle is called the concha, from a Greek 
word meaning concave shell. This concavity passes into the 
meatus auditorius externus, or outer opening of the ear. Above 
the concha, and separated from it by a projection, is a depres- 
sion of a triangular shape, fossa triangularis. 

Elastic fibrous bands, springing from the malar bone and 



MUSCLES OF THE AUEICLE. 83 

mastoid process, fasten the auricle in its position, and allow it 
a certain mobility. The auricle is completely covered by the 
common integument of the body. This integument is more 
firmly adherent to the anterior surface of the cartilage than to 
the posterior, and from it, at the extremity of the ear, a projec- 
tion or tip, called the lobe, is formed. The lobe or lobule con- 
tains no cartilage, only fat and tough connective tissue. It is 
also poorly supplied with blood and nerves, and is consequently 
not very sensitive. It is very distensible, and when over-bur- 
dened by heavy ear-rings may become very much elongated, and 
thus its beauty be greatly marred. 

In rare cases serious inflammatory reaction follows the 
usually harmless operation of piercing the ears for the wearing 
of ear-rings. Gruber * observed that the lobe contained cartilag- 
inous structure in one case of this kind that he observed in his 
practice. He thinks that the inflammation was due to a wound- 
ing of the perichondrium. 



MUSCLES OF THE AURICLE. 

There are three muscles which move the auricle, and which 
are attached to the surrounding parts. They are — 
I. Levator or Attollens auriculam. 
II. Attrahens auriculam. 
III. Retrahens auriculam. 

They are placed immediately beneath the skin. In man they 
are usually rudimentary ; but they are the analogues to certain 
large and important muscles in some of the mammalia. 

Some persons, and especially those whose hearing has be- 
come impaired from chronic aural disease, acquire considerable 
power in employing these muscles, as well as the intrinsic ones. 
I have often observed their action when patients were listening 
for the ticking of a watch, which was being gradually ap- 
proached to the ear, and it may be observed when such persons 
are attempting to hear distant sounds. 

The levator is the largest of the three muscles. It is thin and 
fan-shaped. It arises from the aponeurosis of the occipito-fron- 
talis, and its fibres converge to be inserted into the upper parr 
of the auricle. 

The attrahens auriculam is the smallest of the three. It 
arises from the lateral edge of the aponeurosis of the occipito- 
frontalis muscle. Its fibres converge and are inserted in front 

1 Lehrbuch, p. 01. 



84 MUSCLES OF THE AURICLE. 

of the helix. This muscle is separated by the temporal fascia 
from the temporal artery and vein. 

The retrahens auriculam consists of two or three bundles of 
fibres, which arise from the mastoid process. They are inserted 
into the lower part of the cranial surface of the concha. 

The names of these muscles indicate their action : the levator 
slightly lifts the auricle, the attrahens draws it forward and up- 
ward, and the retrahens draws it backward. 

Hyrtl states that no brute has a lobe as a part of the auricle, 
and that none of the mammals living in water have an auricle. 1 



INTRINSIC MUSCLES. 

The auricle has also a set of muscles which are contained 
within its structure ; intrinsic muscles, as they are called by 
several authors. With a single exception these muscles run be- 
tween different parts of the cartilage of the auricle and of the 
auditory canal. 

They are all muscles of animal life, but they are very slightly 
developed, and are therefore pale, and thin, and flat. They lie 
closely upon the cartilage, and are inserted into its fibrous cov- 
ering by means of short tendinous fibres. They are sometimes 
absent. It is possible, although not certain, that they always 
exist at birth, but that they subsequently atrophy from want of 
use. Two of these intrinsic muscles of the auricle belong to the 
cartilage of the auditory canal, the remainder to the auricle. 
The former occasionally run over into the latter. 

1. Tragicus. — This muscle lies on the anterior surface of the 
anterior wall of the cartilage of the auditory canal, near the 
upper and the lateral border. It is quadrangular in shape, and 
nearly as long as it is broad. It is composed of parallel fibres 
running nearly in a vertical direction. (See Fig. 23, 4.) 

2. Anti-tragicus. — This muscle lies on the posterior sur- 
face of the posterior wall of the cartilage of the meatus. (See 
Fig. 23, 5.) 

3. Helicis Minor. — Henle says that this is the most con- 
stant of the muscles of the auricle, and that it is often the 
strongest of the intrinsic muscles. It is a fan-shaped muscle, 
and is found on the lateral surface of the helix between its root 
and spine. (Fig. 23, 3.) 

4. Helicis Major. — This muscle runs over the anterior mar- 
gin of the helix, and is only loosely connected with it, and passes 

1 Lelirbucli der Anatomie des Menschen, Bd. II., p. 517. 






MUSCLES OF THE AUEICLE. 



85 



over by a kind of tendinous termination into the levator of the 
auricle. (Fig. 23, 2.) 

5. Transversus Auriculae. — Transverse Muscle of the Au- 
ricle. — This muscle consists of fibres which are not very thickly 
combined with loose connective tissue fibres, that run on the 
posterior surface of the auricle from the scaphoid fossa to the 
concha over the deep furrow corresponding to the anti-helix. 
(Fig. 24.) 

6. Oblique Muscle of the Auricle. — Obliquus Auriculce. — 



IUl *.,///; 




Fig. 23. — Muscles of the External Ear (after Henle). Jf, meatus auditorius extemus ; If", 
spine of the helix ; 1, attollens, or levator auriculam ; 2, helicis major ; 3, helicis minor ; 4, 
tragicus ; 5, anti-tragicus. 

This muscle bridges over the furrow on the posterior surface of 
the auricle, which corresponds to the prominence on the surface 
of the cartilage that forms the lower, sharp root of the anti- 
helix. (See Fig. 24, O.m.) 

7. Dilator of the Concha. — Musculus incisurce major is au- 
riculce Santorini. — Sometimes the above-named muscle is found 
on the tragus. 



Hyrtl ' has found it arising from the anterior 



1 Hyrtl, loo.Oit., p. 518. 



86 



BLOOD-VESSELS OF THE AURICLE. 



circumference of the external meatus, whence it runs downward 
and outward to the lower border of the tragus, which it draws 
forward, and thus enlarges the space of the concha. The same 
author says that he knows of no instance of the voluntary 
change in form of the auricle by the action of this muscle. 

"The power of moving the auricle as a whole, is, however, 
by no means very rare. Haller speaks of many such cases, and 
B. S. Albin, the greatest anatomist of the eighteenth century, 
used to take off his wig at his lectures, to show his students how 
easily he could move the muscles of the auricle." 

Duchenne and Ziemssen, 1 by means of faradization, found 



E.f.t. — _ 



E.c. 




Cm. 



Fig. 24. — View of the Cartilage and Muscles on the Posterior Surface of the Auricle (after 
Henle). E.s., elevation made by scaphoid fossa ; E.c, elevation formed by concha; O.m., 
oblique muscle; E.f.t., eminence made by fossae triangularis; T.a., transversus auriculae; 
Cm., cartilage of the external auditory canal; * attachment to the edge of the osseous 
canal ; C.c, cartilage of trie auricle ; C.h., cauda helicis. 

that the muscles of the cartilage of the meatus narrowed the 
incisura auris, and thus the canal leading into the ear, prevent- 
ing a portion of the sound undulations from reaching the mem- 
brana tympani, while, according to Duchenne, the helicis major 
and minor lift up the helix, and thus favor the access of the 
sound waves. 



BLOOD-VESSELS OF TEE AURICLE. 

Arteries : 

1. Posterior auricular, from the external carotid. 

2. Anterior auricular, from the temporal. 

1 Henle, loc. cit. , p. 729. 



NERVES AND PHYSIOLOGY OF THE AURICLE. 87 

(The temporal is the smaller of the two terminal branches of 
the carotid.) 

3. An auricular branch of the occipital. 

It will thus be seen that the blood-supply of the auricle is 
entirely from the external carotid artery. 

The veins of the external ear empty in part into the temporal 
vein, as well as into the external jugular, or into the posterior 
facial vein. 

NERVES OF THE AURICLE. 

The nerves are the — 

1. Auricularis magnus, from the cervical plexus. The cer- 
vical plexus is formed by the anterior branches of the four upper 
cervical nerves. 

2. Posterior auricular, from the facial. 

3. An auricular branch of the pneumogastric. 

4. An auriculo -temporal branch of the inferior maxillary 
nerve. 

The branches of the cervical plexus are on the posterior side 
of the auricle. 

PHYSIOLOGY. 

The exact functions of the auricle still remain in doubt. We 
do not yet know to what extent, if any, the perception of the 
point of origin of sound, or the conduction of sound to the 
membrana tympani are assisted by the muscles of this part. Ac- 
cording to Hensen, 1 the results of experiments as yet made are 
contradictory. Those that indicate much importance to the 
functions of the auricle are of doubtful significance, while those 
that indicate that the auricle is what we may call a rudimentary 
part are more positive. In 1832 Esser 2 showed that the reflec- 
tion of sound-waves from the individual parts of the auricle do 
not assist much to their entrance into the auditory canal. It 
was also observed by Harless, 2 that the perception of sound was 
not weakened when a long glass tube was placed tightly in the 
passage, even when the body causing the sound lay far out- 
side of the direction of the axis of the canal. Mach's 3 experi- 
ments also showed that the different parts of the drum-head 
were not differently affected according to the direction of the 
sound. Schneiders experiments are even more positive against 



1 Handbnch der Physiologie, von L. Hermann. Gehor von V 

Leipzig, 1880. 

- Hensen, loc. cit. 

3 Archiv fur Ohrenheilknnde, S. 72. 1874. 



88 PHYSIOLOGY OF THE AUKICLE. 

the influence of the auricle. He filled the depressions of the 
auricle within and without with wax, only leaving the canal 
free. The canal then being directed toward the source of sound, 
tones were rather intensified than weakened. Hensen concludes 
from Schneider's observations, that the direction of the auricle 
toward the source of sound, has less influence upon the distinct- 
ness of perception than does the opening of the canal with a 
good round meatus. Sounds, according to the same author, are 
most distinctly perceived, when they fall upon the ear sideways. 
It remains an open question if vibrations of more than one 
thousand times a second can be concentrated on the auricle by 
reflection. On the other hand, Binne, experimented upon an 
auricle filled with dough, and he found the tick of a watch was 
heard further when the auricle was uncovered. Politzer 1 thinks 
that the concha is the important part of the auricle in assisting 
the hearing. He found, on examination of persons hard of hear- 
ing, that the limit of audition was nearer the head as tested 
with the metronome, when the concha was covered by a stiff 
piece of paper, while no alteration in the hearing distance was 
observed if the other depressions of the auricle were covered. 
Politzer also regards the tragus as of great importance for the 
reflection of waves of sound that strike the auricle. Ktipper 2 
denies that the auricle has an} r influence upon the ear in the 
way of reflecting the waves of sound, or as an elastic body 
vibrating with the waves and conducting them directly to the 
deeper parts. He insists that Boerhaave's notion that the un- 
dulations, after long wandering, are united in the auditory canal 
by the depressions of the auricle is incorrect, and he believes 
that the auricle cannot perform any such office, but that a mem- 
brane like the membrana tympani is necessary for this. He 
reminds his readers that birds whose hearing power in every 
respect exceeds that of man, have no auricle. Kiipper adopts 
the theory of Darwin and Haeckel, and classes the auricle 
among the organs that evolution has rendered useless in man 
except as appendages, in this case as an ornamental one. Mach 3 
confirms Klipper's views, but he considers that the auricle is 
a resonator for high tones, such as the rustling of the grass, 
the leaves, sounds important to animals, but even this function 
he believes only exists to a slight degree in man. Burnett 4 
claims to have anticipated Mach's views in regard to the reson- 



1 Text-book, p. 61. Translation. 

2 Archiv fur Ohrenheilkunde, Vol. IX., p. 76. Xeue folge, Vol. III. 

3 Loc. cit. 

4 Text-book, p. 34. 



PHYSIOLOGY OF THE AUKICLE. 89 

ating capacity of the auricle, but the experiments of Burnett 
include the external auditory canal. In the opinion of the latter- 
named author, the absence of an auricle in birds does not argue 
against its utility as a resonator in man, for the wave lengths 
of the high notes used by birds are so short that they resound 
well in their shallow auditory canal. Dr. Sexton, 1 as the result 
of some experiments upon the living subject, concludes that the 
range of hearing for the tuning-fork is increased in some per- 
sons, when the occipito-f rontalis muscle is contracted. He thinks 
that this muscle acts as an auxiliary to the attollens auriculam 
and attrahens auriculam. As the result of one dissection of the 
human subject, he found that traction of the deep temporal fascia 
moved the auricle freely. He also found that when alternate 
tension and relaxation were practised on the same fascia, the 
drum-head also became tense or relaxed, the motion being visi- 
ble. The anatomists describe the occipito-frontalis as a muscle 
which occasionally has muscular slips extending to the pos- 
terior auricular muscle. It is possible that in exceptional cases 
the action of the former muscle would affect the auricle as well. 
The action of the deep temporal fascia upon the drum-head, as 
described by Dr. Sexton, is with difficulty conceived of, when we 
remember that the drum-head is nearly surrounded by bone, and 
only connected through the handle of the malleus with soft 
parts — the tensor tympani muscle. How the action of this mus- 
cle can be influenced by traction of the deep temporal fascia, I 
cannot determine. 

The relations of the muscles of the auricle to the occipito- 
frontalis, are well shown in the cut from Sappey on the next 
page. In the exceptional cases in which the power of moving 
the occipital and frontal muscles, as the occipito-frontalis is 
called by the French anatomists, it is readily seen that the auri- 
cle may also be moved. 

A careful study of all that has been written upon the physi- 
ology of the auricle, as well as observations upon the living sub- 
ject, render it tolerably clear to my mind, that the auricle is 
really, as Darwin and Hackel claim, only a rudimentary organ. 
and not of value in hearing, except under exceptional circum- 
stances. Even if the tick of a watch be heard further, as Rhine 
and others show, when the concha be uncovered, this by no 
means proves that conversation is heard further by its aid. since 
the test by the tick of a watch is a fallacious one as compared 
with that by human speech or the notes of music. It is probable, 
however, that the rudimentary capacity of the auricle as a res- 



1 Medical Record, November 17, 1883, 



90 



MUSCLES OF THE AURICLE. 



onator is greatly increased by placing the hand behind it, and 
that those whose hearing is impaired, may sometimes increase 
their hearing power in this way. If this were not the case, the 
human race would have long ago abandoned the habit. 




Fig. 25. — The Muscles of the Head (from Sappey). 1, Posterior auricular muscle, having 
two sets of attachments, a superior very short, an inferior much longer ; 2, superior auricular 
muscle ; 3, anterior auricular muscle ; 4, occipital muscle; 5, section of the aponeurosis which 
extends from the occipital muscle to the superior auricular ; 6, aponeurosis, extending from the 
occipital and running under the inferior surface of the auricular superior ; 7, superior fibres 
of the superficial temporal muscle, situated at the termination of the two parts coming from 
the occipital muscle ; 8, lower fibres of the superficial temporal, united to the anterior auricu- 
lar by a fibrous band which forms a part of the epicranial aponeurosis. 



EXTERNAL AUDITORY CANAL. 

The canal leading from the auricle to the membrana tym- 
pani consists of two portions, an outer part, which is formed of 
cartilage, and an inner, which is of bone. 

Its external opening, which is formed by the cartilaginous 
portion, corresponds anteriorly and below with the margin of 
the external ear. Behind, it is demarcated by the ridge which 
connects the anterior border of the auricle with the margin of 



EXTERNAL AUDITORY CANAL. 



91 



the osseous meatus ; above, it is bounded by the root of the 
helix. 

Inasmuch as the membrana tympani is not on a plane per- 
pendicular to the walls or sides of the canal, these do not ex- 
tend equally far inward. The anterior and inferior wall is the 
longest. It thus becomes impossible to give an exact measure- 
ment of the canal which can be applied to all ears. The canal is 
also curved, and its cartilaginous portion is very elastic. 



2 3 




\» 11 



CM 

Fig. 26. — Section through the External Meatus and the Ear at the Point of Junction of 
the Cartilage of the Auricle, CC, with that of the Auditory Canal (after Henle). A small 
portion of the upper wall of the latter remains as a narrow band, CM' ; CM", lower wall of 
the cartilage of the external meatus ; H", spine of the helix ; L, lobe of the ear ; * fibrous 
lip of the border of the osseous meatus ; 1, epicranius temporalis muscle ; 2, levator anricu- 
laris ; 3, temporal muscle ; 4, upper wall of the osseous canal ; 5, cavity of the tympanum : 
0, membrana tympani ; 7, stapes bone ; 8, vestibule ; 9, meatus auditorius interims and acous- 
tic nerve ; 10, lower wall of the osseous meatus ; 11, parotid gland. 



The first curvature is described by Henle as zigzag in shape. 
and is well shown in the two cuts from his work on anatomy. 
This curvature is constant. These curvatures may be overcome. 
and the outer portion of the canal rendered nearly if not quite 
straight, by drawing the auricle upward and backward. The 
cartilaginous portion of the canal is interrupted, especially on its 
inferior wall, by gaps and fissures — the so-called Tncisurce San- 
tor int. These gaps are filled up by fibrous tissue. The osseous 



92 



EXTERNAL AUDITORY CA^AL. 



portion is an integral portion of the temporal bone, and has a 
groove for the insertion of the membrana tympani. (Sulcus pro 
membrana tympani. — Hyrtl. ) 

The length of the canal, according to Hyrtl, varies from 9 




Fig. 27. — Horizontal Section of the Head, through the External Auditory Canal (after 
Henle). 1, Cartilage of the external auditory canal ; * fissure in the cartilage ; 2, cartilage of 
the auricle ; 3, tuberculum articulare of the lower jaw ; 4, fossa mandibularis ; 5, membrana 
tympani ; 6, cavity of the tympanum ; 7, vestibule ; 8, transverse sinus ; 9, mastoid cells. 

lines to one inch. The average length of the canal, according 
to Troltsch, ' is about 24 millimetres. The cartilaginous portion 
forms about one-third of this, or 8 mm., and the osseous canal 
the remaining two-thirds, or 16 mm. 

The angle which the upper wall of the canal 
forms with the membrana tympani, is an obtuse 
one ; but that between the lower wall and the 
drum-head is acute ; it is one of about 45°. 

The width of the canal varies as well as the 
length. It is widest at the junction of the osseous 
with the cartilaginous canal, and next to the mem- 
brana tympani. 
The casts made by Dr. F. M. Wilson, as here delineated, con- 
firm Hyrtl's and Sappey's moulds of wax, and show that the 
canal is a spiral turning anteriorly inward and downward. 




Fig. 28.— Annu- 
lus Tympanicus 
(actual size, from 
Professor Dar- 
ling's museum). 



1 Treatise on the Ear, second American edition, p. 18. 



EXTERNAL AUDITORY CANAL. 



93 



The auditory canal is lined by integument, and not by mu- 
cous membrane. Hence it is not correct to speak of a catarrh 
of the external auditory canal. This integument is merely a 
continuation of that of the general 
surface of the body. The nearer it 
approaches the membrana tympani, 
the thinner it becomes, and finally it 
covers the drum-head as a very thin 
layer. 

" The integument of the cartilag- 
inous portion of the canal is 1^ mm. 
thick, and contains soft hairs, with 
their sebaceous glands, the cerumi- 
nous glands, and a little fat in its sub- 
cutaneous tissue. In the OSSeOUS part chian tube ; 5, fenestra ovalis ; 6, 
Of the Canal, the integument is Only P ositio * of membrana tympani ; 7, 
_ _, • xi • i xi i?x i • posterior opening of mastoid. 

0.1 mm. in thickness, the sott hairs 

become very few, and the ceruminous glands are found only on 
the posterior upper wall, where they are generally seen, even 
close to the membrana tympani. Small papillae are found 




Fig. 20.— Cast of Auditory Canal 
and Adjacent Parts (actual size). 1, 
External auditory canal ; 2, mastoid 
cells ; 3. tympanic cavity ; 4, Eusta- 




Fig. 30. — Section of Left Temporal Bone (actual size, from Professor Darling's museum). 
1, Styloid process ; 2, carotid canal ; 3, promontory ; 4, floor of tympanic cavity over carotid 
canal ; 5, mastoid cells ; G, external auditory canal. 

arranged in rows under the cuticle, and also a corium with 
abundant elastic fibres, of which the lower layers pass into the 
periosteum." ! 

The ceruminous glands are like the sudoriparous or sweat 



1 The Organ of Hearing. J. Kessel, Strieker's Manual, p. 951. Translated by J. 
Orne Green. 



94 EXTERNAL AUDITORY CANAL. 

glands in their development and secretion. The only difference 
between the secretion of the two kinds of glands, is that the 
ceruminous glands contain some coloring matter. (Cerumen is 
probably derived from cera aurium. — Hyrtl.) 

The substance of the ceruminous glands is a yellowish-white, 
rather fluid material, which consists essentially of fat-globules, 
coloring matter and cells in which single globules of fat and 
coloring matter are embedded ; there are also hairs and scales 
of epidermis from lining of the meatus (Kessel). When the 
cerumen has remained in the canal for a long time, its watery 
contents are lost by evaporation, and it becomes a hard mass. 

Sometimes the hairs of the canal grow to such a length as 
to obscure the view of the meatus and the drum-head. In such 
cases I have been obliged to remove them with a pair of curved 
scissors. By rubbing upon the surface of the membrana tym- 
pani, they may cause a tickling sensation in the ear and become 
a source of annoyance. Dr. R. F. Weir relates such a case. 1 

According to Buchanan, an author who laid too much stress 
upon the part which the cerumen plays in the economy, there 
are from one thousand to two thousand ceruminous glands. 

The child at birth, and for some time after, has no osseous 
meatus. The cartilaginous portion is at first attached to a mem- 
branous part, just as it is afterward to the osseous portion. 

Gruber 2 thinks that there is a very narrow rim of osseous canal in the last 
months of embryonal life. 

In the newly born this membranous portion constitutes about 
one-half of the canal ; but it gradually becomes shorter as the 
bone grows outwardly. 3 

This ossification proceeds irregularly, and often leaves a for- 
amen, which, according to Troltsch, has been mistaken for a 
pathological condition, the result of caries. An inflammation 
of the meatus in a young child, as shown by the same author, 
might readily pass through this foramen to the maxillary articu- 
lation or parotid gland. 

The auditory canal of the dog and cat are closed at birth, as 
are their eyelids. There is, perhaps, as Troltsch suggests, an an- 
alogous condition in the closure of the meatus of young children 
with vernix caseosa, and the approximation of the walls of the 
meatus, near the membrana tympani. 

Some birds have the power of stopping their ears by a kind of 

1 Transactions American Otological Society, third year. 

2 Monatsschrift fur Ohrenheilkunde, Bd. II., p. 67. 

3 Troltsch, loc. cit, p. 6. 



RELATIONS OF THE AUDITORY CANAL. 



95 



valve. The turkey has a kind of erectile tissue projecting into 
the meatus, so that it can close the ears more or less perfectly 
when angry (Troltsch). 



RELATIONS OF THE AUDITORY CANAL. 

The cartilaginous portion is bounded anteriorly and inf eriorly 
by the parotid gland. Cases have been observed where abscesses 
of the parotid have discharged into the auditory canal, through 
the fissures of Santorini. This occurred during the fatal illness 
of the late President Garfield, while he was suffering from sup- 
purative parotitis. Enlargements of the parotid or lymphatic 
glands may contract the calibre of the canal by pressure. 

The anterior wall is also in relation with the posterior wall of 
the articular fossa of the inferior maxillary bone. Hence a blow 




Fig. 31.— External Surface Left Temporal Bone (two-thirds size), 
zygomatic process ; 4, styloid process ; 5, external auditory canal ; 6, 
panic process ; 8, vaginal process ; 9, mastoid foramen. 



2, Mastoid process ; 3, 
glenoid fossa ; 7, tym- 



upon the chin may produce a fracture of this plate, and cause a 
hemorrhage from the ear. The thick articular cartilage protects 
the auditory canal and temporal bone from the full force of such 
a blow. 

The posterior wall is made up by the mastoid process in such 
a way, that the canal is only separated from the transverse sinus 
by two thin plates of osseous tissue and the air-cells lying- be- 
tween them. The superior wall is covered on its upper surface 
by the dura mater, and forms a portion of the floor of the mid- 
dle fossa of the skull (Troltsch). 

The wall between the integument of the canal and the dura 
mater, may be exceedingly thin, and inflammations of the mea- 
tus may produce disease of the brain. 



96 EXTERNAL AUDITORY CANAL. 

The auditory canal is bounded above and behind by portions 
of the mastoid cells, that are included in the "middle ear," so 
that, strictly speaking, a portion of the mastoid part of the 
middle ear is situated beyond the membrana tympani. Inflam- 
mations of the mastoid, in not unfrequent cases, occur with no 
perforation of the membrana tympani, and the pus evacuates 
itself in the auditory canal. The importance of these relations 
was first fully pointed out by Troltsch. 



BLOOD-VESSELS OF THE AUDITORY CANAL. 

1. Posterior auricular artery, which also supplies the auricle. 

2. Deep auricular, from the internal maxillary. It enters at 
the articulation of the lower jaw, supplies the tragus, and then 
gives off branches to the canal. 

NERVES. 

1. From the third branch of the tri-facial or fifth nerve. 
These enter through the anterior wall, between the cartilaginous 
and osseous portions. 

2. An auricular branch from the pneumogastric, which en- 
ters the anterior wall of the bony canal. 

This auricular branch was first described by Arnold in 1828. 

The effect of irritation of this branch is often seen by the 
cough produced when the aural speculum is pressed upon it, or 
when the part is touched by a probe. 

PHYSIOLOGY. 

The length and curvature of the auditory canal prevent the 
membrana tympani and auditory canal, under ordinary circum- 
stances, from being injured by wind, changes of temperature, 
and the like. The cerumen probably also guards against the 
frequent entrance of insects. The auditory canal increases the 
power of tones by acting as a resonator. 1 

1 Hensen, loc. cit. 



CHAPTER IV. 

THE MALFOEMATIONS AND DISEASES OF THE AURICLE. 

A Finely Formed Auricle an Indication of Character. — Malformations. — Superfluous 
Auricles. — Ely's operation for Prominent Auricles. — Tumors. — Angiomata. — 
Othcematomata. — Perichondritis.— Malignant Growths. — Syphilitic Affections. — 
Erysipelas. — Effects of Gout, 

A finely formed auricle is justly esteemed one of the marks of 
personal beauty. The celebrated physiognomist, Lavater, also 
attached considerable importance to this part as a means of de- 
termining character. A humorous German critic, quoted by 
Voltolini, in speaking of Lavater's ideas of physiognomy, says : 
" It would be very queer of Dame Nature, if she had hung every 
one's character on the nose, so that any one who was a master 
in physiognomy could read it. Perhaps fearing this, some 
people shut their eyes and are ashamed to look one in the face." 
A French author, Dr. Amedee Joux, quoted by Troltsch, goes 
much farther than Lavater in his estimation of the signification 
of the auricle. Besides the part which it plays in indicating hu- 
man character, he claims that, more than any other organ of the 
body, it descends with its particular form from father to child, 
and that by the shape of the auricle we may be assisted in deter- 
mining the legitimacy of children, and the conjugal fidelity of a 
mother. He says, " Montre-moi ton oreille,je te diraiqui, tu es, 
cVoii tu viens, et oil tu vas" or, as we should say in English, " Let 
me see your ear, and I will tell you who you are, where you came 
from, and where you are going." 

I am inclined to think that this view of the importance of the 
auricle is somewhat fanciful. Whatever may be the significance 
of the auricle, as regards character or legitimacy, its perfect 
shape has very little to do with the power of hearing. Whether 
it lies properly fitted to the head, and has all its parts of helix, 
fossa helicis, beautifully shaped, or whether it laps over like that 
of an inferior animal, or be a shapeless appendage, makes very 
little difference in the power of hearing music or the human 
voice. As we have seen in the discussion in the preceding chap- 
7 



98 MALFORMATIONS OF THE AURICLE. 

ter, the functions of the auricle are like its muscles — unimpor- 
tant and rudimentary. 

We may conveniently classify the prominent affections of 
the auricle as follows : 

1. Malformations. 

2. Tumors, benign and malignant. 

3. Syphilitic diseases. 

4. Othsematomata. 

5. Perichondritis. 

6. Eczema. 

7. Effects of Gout. 

8. Erysipelas. 



I. —MALFORMATIONS. 

Many of the so-called malformations are the natural results 
of ill-treatment of the auricle. Many women, especially those 
of the lower class, cover their ears so tightly with their hair, cap 



Fig. 32. — Case of Prominence of Auricles. 



and hood, that they finally, by the excessive pressure, flatten out 
and fill up the natural elevations and depressions which go to 
make a finely shaped auricle. Children's auricles are sometimes 



PROMINENCE OF AURICLES. 99 

injured in their passage from the womb to the world. Boys often 
get into the bad habit of pressing their caps down upon their 
ears. They thus cause them to lap over and give them the un- 
sightly appearance known as " dog ears." A boy, twelve years 
of age, presented himself in 1881 at the clinic in the Manhattan 
Eye and Ear Hospital held by myself and Dr. Ely, complaining 
that he was ridiculed by his companions on account of the 
prominence of his ears. He desired, if possible, that an opera- 
tion be performed which should relieve him from this annoy- 
ance. The accompanying cut gives a good idea of the degree of 
the deformity of one side. It was equally deformed upon the 
other side until relieved by Dr. Ely's operation. The second cut 




Fig. 83. — Case of Prominence of Auricles. 

gives a good idea of the back view of the auricles before and 
after the operation. 

Dr. Ely describes his operation as follows : ! The right ear 
was first operated upon. An incision was made through the 
skin, along the entire length of the furrow formed by the junc- 
tion of the auricle with the side of the head posteriorly. This 
was joined at each end by a curved incision carried over the 
posterior surface of the auricle, and the skin and subcutaneous 
tissue included by these incisions were dissected off. Two in- 
cisions, nearly parallel to the former ones, were then carried 
through the cartilage, and an elliptical piece of the latter, meas- 



1 Archives of Otology, Vol. X., No. 3, p. 97. 



100 PROMINENCE OF AURICLES. 

Tiring 1-J inch by J inch, was removed. The pieces of excised 
skin were considerably larger than this. The edges of the 
wound were then united by ten sutures, of which seven only 
included the skin, while three passed through both skin and car- 
tilage. Owing to the natural folds of the cartilage, it was im- 
possible to secure perfect coaptation on the anterior surface of 
the auricle, and a small space was here left to heal by granula- 
tion. The dressing consisted of absorbent cotton and a bandage. 
Healing ensued with very little pain or swelling — the posterior 
incision united by first intention and the anterior wound by 
granulation. The sutures were removed on the fourth day. 

Dr. Ely varied the operation upon the left ear somewhat, by 
transfixing it with a scalpel and excising a piece of cartilage 
of the desired size and shape, together with its overlying skin. 
Additional skin was then removed from the posterior surface. 
Three sutures were used through the cartilage on its anterior 
surface and one on the posterior. The dressing was absorbent 
cotton and a bandage. Complete union by first intention was 
not obtained, but the result was as satisfactory as in the first 
ear. Ether was used as an anaesthetic for both operations. The 
posterior cicatrices were hidden by their position, and those on 
the anterior surface are hardly noticeable. The hearing was 
normal before and after the operation. The boy expressed him- 
self as entirely satisfied with the result, and came of his own 
free will for the operation on the second ear, some weeks after 
the first had been operated upon. 

I have since performed the operation in one case, in the man- 
ner which Dr. Ely performed his first operation, and I append 
the note of the father of the child, a physician, as to the result. 
Dr. S writes : 

Dear Doctor : 

Before the operation the auricle projected at the extreme point l£ inch ; 
the left ear 1 inch. Since healing the projection is {. There is a red cicatricial 
spot on the auricle that shows, but would not ordinarily be observed. He is so 
much improved that people would not now notice anything unusual about the 
ears ; but before, both being prominent, and one much more so than the other, 
it was observed by every one. 

The detachment of the auricle is by no means a formidable 
operation, and I can cordially commend Ely's method as an ex- 
cellent means of removing the deformity of prominent auricles. 

ARRESTED DEVELOPMENT— MICROTIA. 

There is a class of malformations of the auricle which has 
the same pathological interest with other forms of arrested de- 



MICROTIA. 



101 



velopment, such as spina bifida, coloboma iridis, etc., but unfor- 
tunately they are also cases for which our art can do nothing. 
I refer to those cases in which the auricle is congenitally ab- 
sent, or where it exists only in a rudimentary form. In such 
instances the cartilaginous and osseous auditory canals are 
usually also wanting, but the middle and internal ear may be 
well developed. 

There are cases, however, in which the whole ear is undevel- 
oped. The deformity usually affects but one ear, but both ears 
are sometimes similarly affected. Attempts have been made by 
surgeons to make a passage to the drum-head and middle ear, 





Figs. 34, 35.— Deformity of Auricles. 



but as yet they have failed. It is probable that the middle ear 
is not in a normal condition, for the impairment of hearing is 
usually, if not always, greater than could be explained by the 
mere absence of a canal leading to the membrana tympani. 

The illustrations seen above, and the account of one case, give 
a fair idea of these deformities, for which art has as yet done 
very little. I have never seen any artificial ears that served any 
good purpose in masking the deformity. In females, the hair 
can be made to do very well in this respect. Fortunately, but 
one ear is usually deformed. 

Superfluous auricles sometimes occur, just as do supernu- 
merary toes and fingers. They are objects of anatomical curi- 



102 DEFORMITY OF THE AURICLES. 

osity rather than of therapeutical interest. Beck 1 details a 
number of cases in which, by freaks of Nature, the auricle was 
placed on the back, the shoulder, and near the angle of the 
mouth. 

The case of which an illustration is given on the preceding 
page, consulted me in 1881, with reference to a relief of the de- 
formity. He was thirty years of age, and was born with a rudi- 
mentary and deformed auricle on each side. There was also bony 
closure of the canal on each side. He understood loud conversa- 
tion some four or five feet away. He heard musical sounds well. 
In this case it is evident that the deformity is confined to the outer 
and middle ear. The patient, as is seen by the cut, is a well-de- 
veloped man. He has learned a trade and succeeds well in it. 
Dr. David Hunt 2 reports three cases from the practice of Dr. 
Blake, in which the deformity of the auricle and the absence of 
the auditory canal constituted the disease of the ear. Hunt be- 
lieves that these malformations originate in the auricle. He 
regards "the association of the malformation of the auricle as 
due to the interruption of a natural order of events, according to 
which a certain stage of development of the auricle precedes 
the formation of the meatus (auditory canal). 

I am indebted to Dr. "William Hunt, of Philadelphia, for an account of de- 
formities of the auricle occurring in five children of one family. The first child, 
instead of an auricle, had a little pedunculated growth in front of the tragus. 
The second had- the same defect, and two similar growths in front of the tragus. 
In a third, the upper part of the auricle was turned over forward. A fourth had 
one auricle half an inch longer than the other. A fifth child, whom Dr. Hunt 
saw when it was two or three weeks old, is described by him as having " no ear 
at all. There were mere nodulated small masses of cartilage and skin, with a 
little point which seemed to be an opening, but was a mere cul-de-sac not more 
than an eighth of an inch deep." Dr. Hunt saw the child again in a few months, 
but the auricles had not developed. It was difficult to tell whether the child 
heard or not. The monthly nurse was positive in her opinion that babies with 
good ears hear at once, and this coincides with the opinion of most nurses, as 
Dr. Hunt and I agree, but as I shall discuss this question in speaking of deaf 
muteism, I merely allude to it here. There was but one child in this family of 
six in whom there was a perfect auricle, although the children were perfect in 
other respects. 

FISTULA OF AURICLE. 

I have seen two, if not more cases of fistulous openings in the 
auricle, which were said to be congenital and from which pus es- 
caped at certain times. In one case these fistula? were associated 

1 Krankheiten des Gehororgans, p. 108. 

2 American Journal of Otology, Vol. HI., No. 1. 



TUMORS OF THE AURICLE. 103 

with one just above the thyroid body. I advised incision of the 
fistulse and the application of tincture of iodine or bichloride of 
mercury to the open canals thus made, but in neither instance 
was my advice followed. Indeed, I only saw the cases inciden- 
tally, the patients having consulted me for another form of aural 
disease, apparently not connected with the fistulous ulcers. The 
patients seemed to fear that a stoppage of the periodical dis- 
charge from these ulcers might do them harm. I should be in- 
clined to regard these fistulse as marks of arrested development 
of the auricle, since they were congenital and not connected with 
any other form of disease of this part. 

They did not communicate with the auditory canal or middle 
ear. Schwartze ' also reports such cases. 

TUMORS. 

The tumors found in the auricle may be divided into the 
following classes : 

I. Fibro-cartilaginous. 
II. Sebaceous. 

III. Vascular. 

IV. Malignant. 

FIBRO-CARTILAGINOUS TUMORS. 

The first-named form is a simple hypertrophy of the normal 
structure of the auricle. 

According to Billroth, 2 these tumors consist chiefly of fusi- 
form cells and connective tissue, and are nothing more than 
hypertrophy of a cicatrix such as occurs on other parts of the 
body after injuries. They seem to occur much more frequently 
among the African than the Caucasian race. I have removed 
several of these growths from the auricles of negro women, 
while I have but rarely seen them among whites. It is not 
true, however, that they never occur in the white race. I re- 
moved one during the past year from the auricle of a German 
woman. I am also informed that they occur very frequently 
among the Africans of the East and West Indies, where they 
grow to an enormous size. 

The etiology of these growths is very simple, if my own ex- 
perience may be trusted on this point. They occur as the result 
of the irritation of the lobes produced by the truly barbarous 

1 Pathological Anatomy of the Ear. Translated by Orne Green, p. 83. 

2 General Surgical Pathology and Therapeutics, p. 551. Translated by 0. E. 
Eaokley, M.D. 



104 FIBRO- CARTILAGINOUS TUMORS. 

custom of piercing the ears in order that ear-rings may be worn. 
They are much more apt to be found in the lower classes, who 
use brass ear-rings, although the growths may occur even if gold 
ear-rings are worn. They sometimes reach an enormous size, 
and become a very serious deformity. If these ornaments are 
considered indispensable, as no doubt they are, ladies should 
wear them by causing them to be clasped around the auricle by 
means of a suitable contrivance now sold by the jewellers and 
very much used. 

One of the older authors, Frank, gives illustrations of the 
proper instruments with which to pierce the ears, with a de- 
tailed account of the operation ; but the efforts of the medical 
adviser should be toward the prevention of the custom rather 
than increasing the facilities for retaining it. 

Dr. Agnew * reports a case of what finally came to be a myxo- 
fibroma of the auricle, which arose from a scratch from a toilet- 
pin. It occurred in a boy ten years of age. At the end of 
eighteen months a tumor occurred at the site of the injury, of 
the size of a buck-shot. It returned almost immediately, and at 
the end of two years it was again removed, and was found to be 
about three times the size of the original growth. Two years 
after, the tumor having returned, it was again removed. Dr. 
Agnew saw the boy when he had reached the age of eleven, and 
removed a tumor from the place from which these tumors had 
been removed. Six months after there was a small nodule in 
the lower end of the scar near the lobule. Removal of this was 
advised, but no subsequent history of the case is given. 

In some cases it is impossible to heal the edges of the open- 
ing made for the ear-rings, so that there are a few females who 
are never able to wear them, on account of the impossibility 
of securing a sound cicatricial border. I once operated for the 
closure of a gap in the auricle, made by the dragging of the ear- 
ring. After paring the edges and uniting them by suture, a 
good result was secured. Wounds in this region heal readily, 
and with a remarkable absence of deformity. Sutures are well 
borne, and the pain in healing is generally very little. 

Fibro-cartilaginous tumors should be removed if they attain 
such a size as to be at all troublesome. The removal is readily ef- 
fected by a V-shaped incision made with strong scissors. The 
edges of the wound are then brought together by sutures. The 
resulting deformity is usually very slight, and is much less than 
that from the tumor. 

Sebaceous tumors should be removed bv enucleation. 



Transactions American Otological Society, 1876. 



ANGIOMATA OF THE AURICLE. 100 



ANGIOMATA. 



Angioma of the auricle is not a common disease. Cases have 
been reported by Mussey, 1 Kipp, 2 Chimani, 3 Politzer, 4 and others. 
Chimani, however, entitles his case a cirsoid aneurism of the 
auricle and meatus. Repeated injections of chloride of iron 
seemed to cure the case, which was thus treated when the pa- 
tient, a boy, was five years of age. In four years the disease 
had returned so as to be troublesome. The tumor was again in- 
jected with chloride of iron ; three injections at intervals of 
some days were made, when the tumor of the auricle had near- 
ly disappeared. That of the canal was removed by the knife. 
Kipp's case was the result of a frost-bite. After an injection of 
chloride of iron in the hands of another surgeon, the tumor in- 
creased in size. The tumor was situated on the outer side of the 
left lobule. It was of the size of a hazel-nut. The tumor was 
situated beneath the skin, which was movable over it, and trav- 
ersed by numerous large veins. Dr. Kipp removed the tumor 
with the knife. The wound healed by first intention. It was 
found to be covered by a fibrous capsule. The tumor itself was 
composed of spongy tissue, similar to the corpus cavernosum of 
the penis. By the microscope the growth was seen to consist 
of a network of connective tissue trabeculae. The walls of the 
spaces were lined with a layer of endothelial cells. Politzer 5 
treated his case by cauterizing the part of the tumor lying be- 
hind the ear with Pacquelin's cautery (thermo-puncture). He 
first tried subcutaneously the largely dilated posterior auricular 
artery. The patient was dismissed cured in ten weeks. The 
auricle had decreased in size by two-thirds and no longer pul- 
sated. 

When an angioma can be readily separated from the sur- 
rounding tissue, enucleation is to be preferred to any other means 
of removal. 

Dr. F. Eve G reported a case of aneurism by anastomosis occur- 
ring in the auricle, which probably started from a congenital use- 
void growth. The whole pinna above and behind the meatus was 
enlarged, soft, of a dull red color and pulsating moderately, A 
humming bruit could be heard on auscultation. The right com- 

1 American Journal of the Medical Sciences, 1853. 

9 Transactions of the American Otological Society, 1875, p. ?!). 

3 Transactions American Otological Society, Blake's report, 1874. 

4 Text-book, p. 084. Translation. 
5 Loc. cit. 

6 London Medical Times and Gazette, May 8, 1880. 



106 SYPHILIS OF THE AURICLE. 

mon carotid and the temporal and posterior auricular arteries 
were enlarged. Hemorrhage had occurred. The whole auricle 
was removed by Dr. Thomas Smith. There were changes in the 
tissue such as increase in the number of arterioles and capillaries, 
hypertrophy of the Malpighian layer of the cuticle, and enlarge- 
ment of the sebaceous glands, which were attributed to the in- 
creased blood-supply. This case is probably essentially of the 
same nature with those described under the head of " Angioma." 
Mussey's case of " aneurismal tumors upon the ear," is a re- 
markable one. There were three tumors. They apparently had 
their origin on a so-called ncevus matemus. An alarming hem- 
orrhage occurred from one of these about a month before Pro- 
fessor Mussey was consulted. They were compressible almost 
to obliteration, and communicated with each other. The com- 
mon carotid on the side of the tumor was first tied ; in four 
weeks, as the tumors were not markedly diminished, the caro- 
tid of the other side was tied. A cure was then obtained. ' 



SYPHILIS OF THE AURICLE. 

Bumstead and Taylor 2 state that only one case of chancre of 
the auricle has been reported. This was by Alb. Hulot, in the 
Ann. de Derm, et Syph., t. x., p. 47. Paris, 1879. The secondary 
manifestations of syphilis are, however, occasionally seen upon 
the auricle. The various syphilitic eruptions may occur here as 
upon the other parts of the common integument. Ulcerative 
processes from syphilis may take place in the auricle. Gummy 
tumors may also occur in this part. It is hardly necessary to 
say anything more with reference to these evidences of con- 
stitutional syphilis, than that they should be subjected to the 
appropriate -constitutional treatment by means of mercury and 
iodide of potassium, while soothing local applications are made. 

HORXY GROWTHS. 

Buck, 3 Burnett, 4 and Pomeroy 5 report horny growths of the 
auricle. Their removal is, of course, easily accomplished. If 
not thoroughly done, the tumors will probably recur. 

1 American Journal of the Medical Sciences, 1853, vol. xxvi., p. 333. 

,J The Pathology and Treatment of Venereal Diseases. Fifth edition, p. 789. 

3 Transactions American Otological Society, 1870. 

4 Treatise on the Ear, p. 231. 

5 Treatise on the Ear, p. 50. 



oth^ematomata. 107 



OTH^EMATOMATA, OR VASCULAR TUMOR OF THE EAR. 

The peculiar effusion of blood which quite often occurs in the 
auricle, and especially among the insane, and which is known 
as othematoma, hsematoma auris, or vascular tumor of the au- 
ricle, has caused quite an amount of discussion among scientific 
observers. Virchow l and E. R. Hun, 2 of Albany, N. Y., are the 
authors who seem to me to have given us the clearest and best 
accounts of this interesting affection, and, in what I am about 
to say, I shall avail myself of their labors, together with some 
experience of my own on this subject. 

The so-called othsematomata may be divided into those of 
idiopathic and traumatic origin. The idiopathic form occurs 
chiefly, though not exclusively, among the insane. I have seen 
two cases occurring in people of sound mind, which corre- 
sponded very well with the descriptions of those occurring in 
the insane as given by Dr. Hun, whose observations seem to 
have been confined to this class. Dr. E. G. Loring has also 
seen one idiopathic case in a sane person. The symptoms of 
the idiopathic form of the affection are as follows : Before the 
tumor appears we find the ear or ears, as the case may be, red 
and swollen, and the face and eyes give evidence of a strong 
determination of blood ; occasionally, however, there is no red- 
ness of the skin, and there is merely some oedema of the auri- 
cle ; among the insane there is no manifestation of general 
ill-health. In a few hours, or it may be days, an effusion of 
blood takes place. The tumor occupies the concha in the main, 
but it extends over the auricle so as to obliterate its ridges and 
cause the usually beautiful part to appear like a roundish red- 
dened tumor, varying in size from a bean to a hen's egg. This 
tumor is evidently of an inflammatory nature, being hot and 
painful. The swelling is usually quite firm, but a careful ex- 
amination will detect fluctuation. 

The vascular tumor of the auricle, judging from Dr. Hun's 
statistics, is much more common among men than women. He 
reports twenty-four cases, of which twenty-three occurred in 
males. The form of insanity was general paresis in eight cases. 
melancholia in six, acute mania in four, chronic mania in four. 
and dementia in two. These statements accord with the views 
of other authors, so that we may conclude that hsematoma 
auris, when occurring in the insane, is a symptom which is 



1 Die krankhaften Geschwulsten, TM. T., p. t;>r>. 
s American Journal of Insanity, July, 1870. 



108 



OTH^EMATOMATA. 



highly unfavorable, and which points to an incurable form of 
disease of the brain. 

The tumor either ruptures spontaneously, sometimes with 
such violence as to spurt the blood to a distance of several feet, 
or, unless interfered with, is gradually absorbed. Spontaneous 
rupture is more common than absorption. 

Dr. Hun's observations show that the traumatic and idio- 
pathic othaematomata are not alike ; for in one case which he 
details, an insane person, already suffering from hsematoma of 
one auricle, received a blow from a broom-handle on the other, 
which produced swelling and ecchymosis, but no hcematoma. We 





FlG. 30. — Othematoma. From a photo- 
graph taken from a plaster cast, when the 
tumefaction was greatest (after Hun). 



Fig. 37. — The same Ear after Rup- 
ture and Contraction had taken place 

(after Hun). 



must, therefore, I think, strictly distinguish the idiopathic from 
the traumatic form. 

The etiology of haematoma is deemed by Hun to be two-fold, 
viz., cerebral congestion and centripetal irritation of the system 
by the emotions ; and he considers either of these causes suffi- 
cient to produce the effusion. In general paresis there is, ac- 
cording to all authors, a tendency to repeated congestions of the 
head, and it is supposed that the blood-vessels of the ears be- 
come so dilated as to favor the effusion. The second factor in 
producing hsematoma auris, centripetal irritation of the sympa- 
thetic from strong emotions, is especially active among the 
insane, because their emotions are not under the control of the 
will. 



OTII^EM ATOM ATA. 109 

Virchow has made the pathology of othsematomata very 
plain, both by his descriptions and the excellent illustrations 
which he furnishes in his great treatise on tumors. He says 
that "the older authors described the affection as erysipelas of 
the auricle occurring in the insane. It was supposed that in the 
hyperemia and general change in the system a hemorrhage 
occurred, which caused a separation of the perichondrium from 
the cartilage ; but in true othsematomata, pieces of the cartilage 
become attached to the perichondrium." 

Case I.— J. A. C , set. 34. General paresis. Admitted January, 1857. 

Insanity hereditary in his family. Discharged June, 1858. Eeadmitted May, 
1859. July 24th, a simple sanguineous cyst was observed in each ear. Effusion 
rapidly took place until the outlines of the auricle were obliterated. Septem- 
ber 30th, the tumors have gradually subsided. Patient died May 10, 1860. 





Fig. 3S.— Showing Amount of Con- Fig. 39.— Shows Separation of Periehon- 

traction after Rupture of Cyst (after drium from the Cartilage (after Hun). 

Hun). 

According to the Berlin pathologist, the morbid process 
seems to be primarily a softening or deliquescing one. induced 
by general disturbances of nutrition, or possibly — although this 
class of cases seems to belong to itself — by local injuries of the 
cartilage. The tumor disappears either by gradual absorption. 
spontaneous rupture, or by the puncture of the surgeon. Coag- 
ula often form, which make a delicate coating over the sepa- 
rated portions, and these afterward serve as means of adhesion. 
When suppuration does not take place, great deformity is apt 
to occur from the thickening and retraction of the sett parts, 
especially of the perichondrium. 



110 OTHvEMATOMATA. 

Case II. — D. M , set. — . Melancholia. Second attack. Hsematoma began 

May 18, 1869. On July 3d had hsematoina on both ears. August 1st the left 
auricle burst at upper portion of concha, and the contents, consisting of fluid 
and clotted blood, were thrown to the ceiling, a distance of twelve feet. Died 
September 9, 1869. A section of the auricles showed that the perichondrium was 
much thickened, and separated from the auricular cartilage on its outer aspect, 
so as to leave a large, smooth cavity, lined with a smooth, shining membrane, 
and containing a few drops of serous fluid. 

Vascular tumors caused by violence should not be confound- 
ed with those occurring idiopathically. Gudden, a German 
writer and physician for the insane, quoted by Virchow, has 
shown that the auricles of ancient statues are very frequently 
ornamented by tumors resembling the vascular effusions seen 
among the insane. In the gallery at Munich the head of Hercu- 
les has such ears. These misshapen auricles are the typical 
marks of the ancient boxers or pugilists. Such fighters wrapped 
their hands in leather, and, thus armed, struck the ears of their 
antagonists ; consequently in the figures of Hercules, Pollux, 
and other classical fighters, a deformed auricle is a regular ap- 
pearance. Other historical personages — the Trojan Hector, for 
example — are represented as having otheematomata. 

To conclude from these observations that the othsematomata 
are always the result of traumatic influences, that they are more 
frequent among the insane because they are very apt to injure 
themselves or be injured by their attendants, seems to me to be 
manifestly incorrect, judging both from Dr. Hun's observations 
and from the fact that these tumors are very uncommon. Even 
the English writers, living in the land pre-eminent for pugilists, 
scarcely mention them. Wilde l describes and gives an illustra- 
tion of one case, however, which seems to have been a hsema- 
toma, but was not recognized as such by the author. It was 
idiopathic in origin. It occurred in a male aged twenty-four, 
and was about the size of a small pear. It occupied the upper 
portion of the left auricle, between the helix and the concha. 
It was treated by incisions, and considerable deformity resulted. 

Toynbee 2 describes these cases under the head of cysts, and 
seems inclined to ascribe a traumatic origin to them, and he 
states that it is the opinion of Dr. Thurnam, physician to one of 
the county insane asylums of England, that they are less fre- 
quent than formerly, on account of the fact that violence is not 
so much employed in the management of the insane. Dr. Thur- 
nam evacuated the contents of the tumors, and used setons, and 

1 Aural Surgery, English edition, p. 164. 

9 Diseases of the Ear, American edition, p. 53. 



OTH^EMATOMATA. Ill 

thus claims to have prevented the deformity to some extent. 
Toynbee mentions but one case, that of a boxer, that he has him- 
self seen ; but his description is not detailed enough to allow us 
to judge whether it was identical with those observed in the in- 
sane. 

Dr. Hun was so strongly of the opinion that the idiopathic 
othematoma are symptoms of insanity, that he considered any 
person having such tumor upon the auricle, even if sane, as 
a person to be carefully observed as to cerebral symptoms. 
This is an opinion of Dr. Hun's which obtained in a conversa- 
tion with him upon this subject. 

While Professor Brown-Sequard was a resident of New York, 
I had an interesting and instructive interview with him on the 
subject of vascular tumors of the auricle. Dr. Sequard has 
found that sections of the restiform bodies, or largest column 
of the medulla oblongata, in animals (Guinea-pigs) will produce 
a hemorrhage beneath the skin of the auricle in from twelve to 
twenty-four hours. This hemorrhage is soon followed by gan- 
grene of the part. I had, through Dr. Sequard's courtesy, the 
opportunity of examining such ears, and of verifying the fact of 
the subsequent gangrene. The hemorrhage usually occurs in 
the fossa navicularis of the auricle. This hemorrhage usually 
takes place on the same side with that of the section. 

Dr. Sequard also stated that sections of the sciatic nerve, by 
reflex action upon the medulla, would produce the same result, 
and that he had produced in his own person flushing of the auri- 
cle by pinching the sciatic nerve. Dr. Sequard believes that dis- 
ease of the base of the brain, which is, however, not always 
attended by insanity, is the cause of hsematoma auris. In the 
human animal, gangrene is not apt to result from the hemor- 
rhage ; probably because the thicker tissue of the human auricle 
has a greater resisting power. 

It will thus be seen that Dr. Sequard's views confirm those of 
Dr. Hun, while they shed a new light upon the clinical observa- 
tions of the latter. 

Meyer x and Blake 2 report cases of othaematomata in which 
pressure and massage were employed in treatment with good re- 
sults. Both of Blake's cases were males, with no trace of other 
physical disease, of sound minds, and with "no antecedent or 
individual history of insanity or intemperance." The first case. 
however, occurred in a pedestrian, being the " champion short- 
distance walker." As Dr. Blake suggests, this occupation, from 

1 Archiv fur Ohrenheilkunde, vol. xvii., p. 3, 
8 American Journal of Otology, vol. Hi., p. 193. 



112 OTH^EM ATOM ATA. 

its severe strain upon the muscles and the circulation, may have 
had some bearing upon the etiology. This patient flushed easily 
under any physical exertion or slight mental excitement. The 
tumor was opened, two drachms or more of bloody serum and a 
little dark blood withdrawn, the cavity was then well probed, 
and sponge pads were adjusted to the anterior and posterior 
surfaces of the auricle and kept in place by an elastic flannel 
bandage. This treatment was continued for a week, and then 
massage was employed four times at the interval of several 
days for about fifteen minutes at each visit by an expert, Dr. 
Graham, of Boston. * ' The tissues were gently and firmly rolled 
between the thumb and finger with gradually increasing force 
until the last five minutes, when the pressure was gradually di- 
minished."' Under this treatment the ear resumed its normal 
appearance in about two months. 

In the second case, that of a teamster, the hemorrhage oc- 
curred the day after the patient had exerted himself very much 
in loading heavy bales of goods. He was a temperate man, but 
undersized, and was occasionally subject to very severe exertion 
in his business. He was seen by Dr. Blake on the very day the 
hemorrhage occurred. The same treatment was applied as in the 
previous case, and on the fifth day the auricle had nearly re- 
sumed its normal appearance, and the patient was discharged. 
Meyers cases did not do quite as well as these. Blake thinks it 
possible that the stuffing of the cavity with picked lint and too 
frequent massage — four times daily, as practised by Meyer — may 
have prevented the best results. 

The result in three of Meyer's cases was very satisfactory ; 
in two of them resorption took place within a few weeks, and 
there was finally no deformity of the auricle. It is interesting 
to note that one parent in each of Meyer's cases had been insane. 
In view of this, Meyer calls attention to Hun's observation, that 
the appearance of othematoma in sane persons usually precedes 
a later mental disturbance, and agrees with my own opinion, 
that while all those suffering from this vascular tumor of the 
auricle may not be insane, yet they probably have some kind of 
disease of the brain. These observations seem to be borne out 
by Brown-Sequard's experiments, and by an analysis of the cases 
of Blake and Meyer. Othsematomata do not seem to occur in 
persons entirely free from cerebral disease. 

From all that has been written of vascular tumors of the 
ear, and from my own experience, I think we may safely af- 
firm — 

First. — That there are two distinct varieties of othaemato- 
mata : Traumatic and Idiopathic. 



PEEICHONDKITIS OF THE AURICLE. 



113 



Second. — That the idiopathic is much more common among 
the insane than among others, but that identically or nearly the 
same affection does occur among the sane. It is probable, how- 
ever, from Brown-Sequard's experiments, that the affection is 
caused by some lesion of the base of the brain, so that although 
persons suffering from vascular tumor of the ear may not always 
be insane, they generally have brain disease. 

Third. — The traumatic form differs from the idiopathic in be- 
ing a simple extravasation of blood from vessels ruptured by 
violence. In such cases the deformity resulting from the spon- 
taneous effusions does not occur, unless among professional 
pugilists, where the violence is frequently repeated, and the auri- 
cle, from repeated hemorrhages, 
assumes a shape like that result- 
ing from a true othematoma. 

Fourth. — The treatment by 
pressure after evacuation of the 
contents, followed by moderate 
massage, seems to give very good 
results and may be confidently 
practised. 

PEEICHONDEITIS AND CHONDRITIS. 

Any inflammation of the in- 
tegument, connective tissue, and 
cartilage of the auricle, leading to 
effusion of serum, blood, or the 
formation of pus, will be apt to 
cause a deformity of the part ; but 
such a case should be distinguished 
from an othsematoma. 

The sketch from a photograph, 
which is here given, shows the Fig. 40. 
result of what was at first an in- 
flammation of the cartilaginous 

portion of the auditory canal. A polypus formed from the pro- 
longed use of poultices for the relief of what was supposed to 
be a furuncle, the inflammation extended to the tissue of the 
auricle, and after a long period of suffering, during which small 
abscesses were formed, which were evacuated after pursuing a 
sinuous course in the integument, the auricle attained the shape 
which is here shown. The hearing power is unimpaired when 
the very small meatus is kept open. 

Several cases of inflammation of the tissues o( the auricle 
8 




-Auricle Deformed by Inflam- 
mation (chondritis). 



114 PEEICHOXDEITIS OF THE AUEICLE. 

have been published since my case was reported in 1873, ! and 
some of the reporters have fallen into the natural error of stating 
that similar cases have not been before noticed. All these cases, 
although differing in minor respects, agree in being essentially 
inflammations of the perichondrium, and in leaving some de- 
formity behind them as a rule. I did not name my case perichon- 
dritis, when it was first reported, but a comparison of the account 
of the case with those of later writers will show, I believe, that 
the various reporters are speaking of the same form of disease. 
Chimani was one of the first, if not the first, to report a case of 
perichondritis 2 of the auricle. His was that of a soldier in the 
Austrian army, who was suddenly seized with a sensation of 
heat and pain in the left auricle, with swelling of its concave sur- 
face. Four days after the attack, when he entered the hospital, 
the whole auricle was a shapeless mass of inflammation. Poul- 
tices were applied, and in three days fluctuation appeared. An in- 
cision was made ; quite a quantity of synovial-like fluid mingled 
with pus was evacuated. It was afterward treated as an abscess 
and dressed with picked lint and a bandage. In two weeks after 
the patient came under Chimani's care, the auricle had recovered 
its normal form and elasticity. Chimani considers this case as a 
primary one of the perichondrium — "an inflammation with the 
formation of exudation.*' The absence of a bluish-red coloring 
and the character of the contents distinguish it from a vascular 
tumor. Dr. Pomeroy's 3 case of abscess of the auricle was one in 
which the disease extended from the tympanic cavity to the 
canal and thus to the auricle. The patient was a man forty-two 
years of age. The auricle did not become involved for some 
weeks after the primary inflammation. The patient was not 
under constant observation, and recovery took place after free 
evacuation of the pus, with great deformity. This case is to be 
classed with those of secondary inflammation of the auricle, such 
as that reported by myself. It may be said here, that it is not 
unusual to see very considerable swelling of the cartilaginous 
part of the canal following an inflammation of the tympanic cav- 
ity. This usually subsides under the use of the warm douche, 
and generally without extending to the auricle. Knapp 4 re- 
ports three cases. The first began as an inflammation of the 
canal, and after some weeks recovered also with deformity. 
The second case was seen but once, and no details are given 
except that there was fluctuation in the concha. The third case 

1 Transactions of American Otological Society. 

2 Arcliiv fur Ohrenheilkunde, Vol. El, p. 171. 

3 Transactions of the American Otological Society, Vol. II., p. 83. 

4 Archives of Otology, Vol. IX., p. 19G. 



PERICHONDRITIS OF THE AURICLE. 115 

was one shown Dr. Knapp by his colleague, Dr. Brandeis. Dr. 
Brandeis' patient had a "mild chronic aural catarrh." There 
was a reddish diffuse swelling of the cartilage of the meatus and 
the adjacent parts of the concha. After an incision watery pus 
escaped, and the swelling disappeared in a few weeks. 

Pooley's case ' occurred in a woman of twenty-one. When 
she came under Dr. Pooley's care, there was the history of a boil 
in the ear ; the swelling extended from the canal to the concha, 
and finally to the entire anterior surface of the concha. It was 
treated by incisions, injections of a weak solution of carbolic acid 
and iodine. Pressure was also employed by means of a bandage. 
The pressure seemed to alleviate the pain. Considerable deform- 
ity of the concha remained. The acute inflammatory symptoms 
lasted for about two months, and, as in all these cases, the long- 
continued suffering, the discharge undermined the general 
health. Pooley does not regard frequent incisions as assisting 
very much, but as perhaps aggravating the case. 

The lobule may be affected in perichondritis and may not. 
The cases reported do not differ in character, but simply in in- 
tensity and course. Dr. Knapp's case, like mine, arose from a 
f uruncular inflammation, and after this suppuration of the drum- 
head occurred. This is an unusual order of things. Whether or 
not the lobule is affected certainly depends upon other causes 
than the existence of a perichondritis. In my case there was 
perichondritis and also a slight affection of the lobule. 

These cases, except that of Chimani, are essentially the same 
with that reported by me in full in 1873. 2 As I then said, the 
extension of the inflammation of the auditory canal to the car- 
tilage and perichondrium of the auricle is unusual. I believe 
with Pooley, that incisions may be too frequently made, and 
that they are rather to be avoided than employed, although not 
entirely given up. 

Kipp s also reports, under the head of "Spurious Othema- 
toma of Both Ears the Result of a Burn," a case of perichon- 
dritis of the auricle. In his case there was scarcely any de- 
formity, simply a wrinkled condition of the fossa of the helix. 
After incision Kipp employed tincture of iodine to the outer and 
inner surface of the swellings. 

It will be seen that Chimani's case is the only one of these 
here reported, that bears any close resemblance, in its origin or 
course, to the othaematomata. The others are clearly like the 



1 Medical Record, 1881. 

8 Transactions American Otological Society. Boston, 1873- 

3 Ibid., 1873. 



116 MALIGNANT DISEASE OF THE AURICLE. 

cases of Dr. Pomeroy and myself, and belong to those of second- 
ary inflammations. While this form of disease, as has been said, 
is rare, the primary form is much rarer. 

Chondritis and perichondritis of the auricle may result by 
simple extension of an inflammation of the cartilage of the 
canal. It is probable that prolonged poulticing may favor such 
an extension. The deformity from such an inflammation will 
be considerable, under the most favorable circumstances, if the 
inflammation once set in. While incisions may be necessary in 
the course of chondritis or perichondritis with abscess of the 
auricle, they should be undertaken with circumspection, for if 
the knife be used too freely the conditions will be aggravated. 
Perichondritis and chondritis may be readily distinguished from 
othematoma, if the disease be seen early in its course, but when 
the canal, if once diseased, has recovered, and the auricle alone 
remains affected, there may be a possibility of error. 



MALIGNANT DISEASE. 

Epithelioma. — The auricle is sometimes, although not fre- 
quently, the seat of malignant disease. I have observed one 
case of epithelioma of this part, in which the whole auricle was 
destroyed, and the disease had invaded the auditory canal. I 
lost sight of the patient after some weeks, and I can give no ac- 
count of the subsequent course of the disease, which was un- 
checked by the treatment adopted — the application of fuming 
nitric acid. Dr. J. Orne Green, of Boston, 1 also reports a case, 
and quotes one from Velpeau. 

Epithelioma of the auricle usually begins as a small papule, 
which finally develops into an open ulcer. This spreads very 
rapidly, involving finally the auditory canal, and, unless ar- 
rested, the deeper parts. Excision or amputation of the parts is 
the only proper treatment. When the auricle alone is involved, 
this is very easily accomplished. In the healing process care 
should be taken, as suggested by Dr. Green, to prevent the 
closure of the meatus by the cicatrix, a result which followed in 
the case reported by him, in consequence of the refusal of the 
patient to remain under observation until the wound was healed. 

Sarcoma. — Sarcomatous tumors may occur on the auricle as 
well as in the auditory canal, where they arise from the carti- 
laginous portion. They grow very slowly, but they may extend 
to the auditory canal, to the middle ear, and even to the laby- 

1 Transactions American Otological Society, third year. 



ECZEMA OF THE AURICLE. 117 

rinth and meninges of the brain. Early removal is the only 

safe means of treatment, and even then the growth may return. 

The accompanying engraving is a representation of a tumor 




Fig. 41. — Tumor of the Anterior Part of Auricle and Auditory Canal. 

of the auricle, apparently beginning in the parotid gland, which 
was seen at my clinic in 1883. The patient is a woman of about 
forty-five years of age, otherwise healthy. 

eczema. . 

Eczema of the auricle is not one of the most frequent affec- 
tions of the ear, as shown by the statistics of eye and ear hospi- 
tals and writers on otology ; but a large number of cases never 
come under the attention of special observers, and are, conse- 
quently, not found in their statistics. Inasmuch as eczema of 
the auricle, is usually attended by the same disease in the audi- 
tory canal, it will be more convenient to speak of them both at 
this time. 

Eczema of the ear, seems to occur more frequently among 
females than males, but it is found in both sexes. The symp- 
toms are the same as those of eczema in other parts of the body. 
with some symptoms peculiar to the ear. The symptoms pecu- 
liar to the ear are redness, swelling, and the formation of ves- 
icles which become pustular, and which finally cover the whole 
region with unsightly crusts, from which a discharge occurs, 
The auricle becomes a misshapen mass, while the swelling and 



118 ECZEMA OF THE AURICLE. 

incrustation of the integument lining the auditory passage and 
membrana tympani impair the hearing to a serious extent. 
Fulness and noise in the ears are then added to the patient's 
other symptoms, and the condition is unpleasant in the highest 
degree. The disease, when left to itself, is apt to have a very 
chronic course, and yet it is very amenable to proper treatment. 
The causes of eczema are not very clear. I have usually ob- 
served it in persons of weak constitutions, and not among the 
strong and vigorous. It rarely occurs upon the auricle alone ; but 
it is usually found in conjunction with the same disease on other 
pares of the body, most frequently in conjunction with eczema 
of the face and head, although it sometimes occurs on the auri- 
cle and in the meatus alone. 

According to Ausspitz, 1 formerly an assistant to Hebra, ecze- 
ma of the ear differs from the same disease as it appears in 
other parts of the body, in occurring with a greater amount of 
swelling and secretion of more serous fluid than is usual, together 
with the more frequent appearance of fissures in the tissue. 

Treatment. — The treatment of eczema is simple, and I have 
usually found the results very good. The advice of Ausspitz, 
to do as little as possible in the acute form, is excellent. The 
auricle should be kept from the air. This may be accomplished 
by the use of oils, powders, or even by a plaster-of-Paris band- 
age. A good application is the formula of Ausspitz : 

B. Flor. Zinci 3 ij. 

Pulv. Alum, 

Amyli Pulv aa 5 3- 

M. Ft. pulv. 

This powder is dusted over the affected portion with a camePs- 
hair brush. If the auricle be excoriated and sensitive, astringent 
solutions of sulphate of zinc may be used. I usually employ 
vaseline or cold cream in the early stages of eczema of the auri- 
cle. Cod-liver oil is also a good application. I endeavor to keep 
the parts constantly covered with such a non-stimulating oint- 
ment as one of those just named. 

At the same time with this local treatment, the physician 
should carefully consider the general state of the patient, since 
in this a cause for the eczema may often be found, which being 
removed by appropriate management, will prevent a relapse of 
the affection. 

Eczema of the auricle and auditory canal is not often brought 

1 Archiv f iir Ohrenheilkunde, Bd. I. , p. 124. 



ECZEMA OF THE AURICLE. 119 

to the notice of the surgeon until it has become chronic. Its 
treatment then may require the greatest patience and care. The 
treatment which I have found usually successful is the following : 
The auricle is carefully poulticed with flaxseed meal until all the 
crusts can be removed, and is then anointed with an ointment 
of the sulphate of iron and simple cerate, in the proportions of 
from one to two grains of the former to a drachm of the latter. 
This ointment is applied as often as may be necessary to keep 
the part constantly anointed, until the vesicles have ceased to 
form. 

The local treatment of the auditory canal is often unsuccess- 
ful from the want of the personal attention of the physician. No 
one who is unable to examine the external opening of the ear 
down to the membrana tympani, can tell when it is or is not 
clean. Without a thorough removal of the material thrown off 
in an eczema, there can be no cure. An eczematous auricle may 
perhaps recover spontaneously, an eczematous auditory canal 
will, probably, never thus return to a normal condition. The 
material thrown off from the inflamed integument collects in 
the narrow passage, and by mechanical irritation increases the 
swelling, and produces the most troublesome symptom of the 
disease— impairment of hearing. The auditory canal should be 
therefore carefully cleansed every day with the syringe and 
angular forceps or cotton-holder, under a good illumination with 
the otoscope, and then an appropriate liquid application be 
made. A liquid preparation is to be preferred to an unctuous 
one, for the simple reason that an ointment will again block up 
the passage, and thus prevent the patient from securing the full 
benefit to his hearing power which the removal of the epidermis, 
crusts, and pus has produced. We may fail to cure many a 
case of disease of the integument lining this part, if we do not 
carry out our own advice ; we should never give over the treat- 
ment into the hands of the parents or attendants of the patient, 
for they will be incompetent assistants. 

The warm douche is very valuable in the treatment of chronic 
eczema of the canal. It allays itching sensations, and is usually 
very grateful to the patient. The use of the douche may be en- 
trusted to the patient himself. It is well to use it very often in the 
early periods of treatment, say once an hour. The warm water 
is a direct antiphlogistic ; I have seen obstinate cases of inflam- 
mation of the canal, that have existed for years cured by its use 
alone. 

The application of nitrate of silver in solutions of from ten to 
forty grains to the ounce, is, I believe, on the whole, the best 
that can be made in the treatment of eczema of the canal. The 



120 ERYSIPELAS OF THE AURICLE. 

disease may be often complicated with aspergillus, or a vege- 
table fungous growth in the canal. Diachylon ointment on a 
little cotton, forms a good application to keep apart the walls of 
the canal at the meatus. 

Bichloride of mercury in solutions of from one-twelfth to one- 
fourth of a grain to the ounce, applied with a dropper or by 
means of the cotton-holder, has proved an efficient remedy in 
my hands in chronic eczema of the canal. 

The only specific remedy for internal use in chronic eczema 
of the auricle, as well as that of the same disease in other parts 
of the body, is arsenic. In chronic cases I usually give Fowler's 
solution in connection with the local treatment, and it is gener- 
ally of great avail. 

I am aware of various other modes of treating eczema, and of 
the almost innumerable applications which are recommended ; 
but I feel confident that that which I have sketched, will serve 
its purpose so well, when modified by individual judgment in 
practice, as to fulfil all reasonable requirements. 

ERYSIPELAS. 

Facial erysipelas often begins at the auricle, and sometimes 
it is limited to this part. It sometimes also occurs in the course 
of chronic eczema. Indeed, erysipelas occasionally has its ori- 
gin in a small eczematous patch or spot near the auricle. It is 
probable, however, that this never occurs if the subject be in 
good general condition. The local treatment that I have em- 
ployed with satisfaction, is an application of a solution of acetate 
of lead, in tincture of opium and water, the famous lead-and- 
opium wash. It is important, especially in delicate subjects, 
that eczematous spots behind the ear be promptly treated, lest 
they become the starting-point of erysipelas. Oxide of zinc oint- 
ment is a good application for small eczematous ulcers. 

THE EFFECTS OF GOUT. 

Calcareous formations are often found in the auricle, in per- 
sons of a gouty habit, as in other parts of the body. These 
symptoms of gout are often accompanied by a great deal of local 
pain, which is sometimes relieved by an unctuous application to 
the hardened and tender parts. Dr. Garrod, 1 of London, first 
called attention to these formations, which he found to be urate 
of soda. They were most frequently found by Garrod on the 

1 Troltsch. : Diseases of the Ear, p. 56. 



EFFECTS OF GOUT — INJURIES. 121 

upper border of the helix, and were supposed not to exist on the 
lower part of the auricle ; but I saw what seemed to be such a 
formation, in the concha of a gentleman who suffered from 
gout. Unlike those cases reported by Dr. Garrod, this spot was 
very painful. 

Where the gouty diathesis exists, it is not uncommon to find 
heat and pain in the cartilage of the auricle. The practitioner 
should be on the lookout for such cases of apparently simple 
dermatitis, for they may indicate the constitutional trouble, 
which will only be relieved by treatment of the general system. 

INJURIES OF THE AURICLE. 

Wounds of the auricle may sometimes be followed by an ery- 
sipelatous inflammation, but this is not apt to be the case. 

They usually heal promptly, without suppuration, although 
inflammation of the cartilage or the perichondrium may result. 
Injuries of the auricle from direct violence, such as pugilists in- 
flict upon each other, generally produce great deformity. The 
treatment of such injuries requires no especial notice in a work 
of this kind. 

ANGIOMA— A NOTE. 

At the February meeting ( 1884), of the New York Ophthalmo- 
logical Society, Dr. E. Gruening reported an interesting case of 
angioma, of which he has been kind enough to furnish me an ac- 
count for these pages. 

In October, 1883, a man, aged twenty-three, consulted Dr. Gruening on account 
of a circumscribed swelling in his right ear. He stated that he had first noticed 
a little growth two years before. He had never suffered from any injury of the 
ear. No congenital anomaly had been observed. He consulted Dr. Gruening 
about the tumor because its pulsating sounds had become very annoying, espe- 
cially in the stillness of the night. There was found a semi-globular, bluish, 
soft, and strongly pulsating tumor occupying the right concha and encroaching 
somewhat upon the lower wall of the external auditory canal. The tumor had a 
diameter of fifteen millimetres at its base, and an elevation of nine millimetres 
above the surrounding skin. Pressure with the fingers easily emptied the tumor, 
but the pulsation was not diminished by pressure upon the arteries of the head 
and neck. The whole mass was excised on October 25th. The incision was 
carried through sound skin and the underlying cartilage was removed with it. 
The copious hemorrhage, venous from the centre and arterial from the edges. 
was arrested by pressure. The wound healed slowly by succulent granulations. 
Four weeks later a soft pulsating cicatrix had formed. 

Dr. Gruening's case is an essential contribution to our knowl- 
edge of this rare affection. If the pulsating cicatrix enlarges or 
is troublesome to the patient, it will be proper to excise it. 



CHAPTER V. 

DIFFUSE AND CIECUMSCRIBED INFLAMMATION OF THE EXTER- 
NAL AUDITORY CANAL. 

Comparative Frequency of these Affections. — Diffuse Inflammation. — Leeches. — In- 
cisions. — Warm Douche. —Fountain Syringe. — Fayette Taylor's Douche. — Method 
of Syringing. — Syringes. — Anodynes. — Desquamative Inflammation. — Furuncles. 
— Local and Constitutional Treatment. — Calcium Sulphide. — Lowenburg's Views. 

The affections of the external auditory canal may be conven- 
iently arranged as follows : 

I. Diffuse inflammation. 
II. Circumscribed inflammation. 

III. Vegetable fungous growths. 

IV. Inspissated cerumen. 
V. Eczema. 

VI. Foreign bodies. 
VII. Polypi. 

VIII. Exostoses and hyperostoses. 
IX. Narrowing and closure of the canal. 
X. Syphilitic condylomata and ulcers. 
To avoid any misconception, I would remark that while 
bony growths (exostoses and hyperostoses) are classed under 
the affections of the external auditory canal, they are generally 
consequences of inflammations of the middle ear. It will there- 
fore be more appropriate to consider this rather important sub- 
ject under the head of diseases of that part. An account of 
their pathology and treatment will be found in the chapter de- 
voted to the " Consequences of Chronic Suppuration of the 
Middle Ear." The subject of "Aural Polypi" will also be de- 
ferred until a subsequent chapter, for they are also much more 
frequently the result of inflammation of the middle ear, than of 
disease of the external auditory canal. Otitis externa is the 
generic term for all the various forms of inflammation of the 
external auditory passage, but it is not specific enough for any 
exact study of these affections. 

Inflammations of the external auditory canal are much more 
rare than those of the middle ear ; of 4,800 cases of the different 



STATISTICS OF INFLAMMATION OF CANAL. 123 

varieties of aural disease observed by myself in private prac- 
tice, but 303 were cases of inflammation of the auditory canal. 
This proportion varies somewhat from the statistics of other 
authors and those of public institutions. 

In the Manhattan Eye and Ear Hospital, during the past thir- 
teen years, there were examined 10,335 cases of aural disease. 
Of these 403 were cases of inflammation of the external auditory 
canal. This does not include cases of impacted cerumen or for- 
eign bodies, or inflammations which had their origin in the parts 
beyond and extended to the canal. Including inspissated ceru- 
men and foreign bodies, there were 1,541 cases of affections of the 
external canal, or about one-sixth of the whole number. 

Dr. Buckner, of Gottingen, has compiled a table of reports 
from various authorities. 3 In a total number of 58,645 cases of 
diseases of the ear thus reported, there were 14,905, or 25.5 per 
cent., of affections of the external ear. 

The highest percentage of diseases of the external ear in 
Btickner's tables is 39.5 (Ocker), the lowest 13.3 (Roosa). In 
Wilde's tables, 2 also quoted by Buckner, the percentage of ex- 
ternal affections is very high, 55.8. Since the time of Wilde it is 
undoubtedly true that our means of diagnosis are better, and we 
are enabled to transfer many cases from the column of the ex- 
ternal auditory canal, to that of the middle ear. 

Some writers speak of the inflammations of the external 
auditory passage as being catarrhal in their nature ; but as 
Troltsch strongly insists, and as has already been said in the 
description of the anatomy of the auditory canal, there cannot be 
a catarrhal inflammation where there is no mucous membrane. 
The lining of this passage is integument, and in no proper sense 
can we speak of a catarrh of the integument. 

An account of diffuse or general inflammation of the exter- 
nal auditory canal will first be given. 



DIFFUSE INFLAMMATION. 

Symptoms. — The subjective symptoms of diffuse inflamma- 
tion of the external auditory canal are itching sensations in the 
canal, pain, and a sense of fulness and heat. 

I speak of these symptoms in the order in which, on careful 
examination of the history of the cases, I have found they usu- 
ally appear. It is true that patients often give a period later 
than that in which the itching: sensations occurred, as the one 



1 Archiv fur Ohrenheilkunde, 1888. 

2 Text-book, English edition, p. 114. 



124 DIFFUSE INFLAMMATION. 

in which their ears first troubled them, but ears in a normal 
state have, so to speak, no sensations ; that is to say, they are 
not thought of, and need no especial care. When an ear be- 
gins to require something to relieve itching sensations, it is 
already diseased. 

The objective symptoms are impairment of hearing, redness 
of the canal and perhaps of the membrana tympani, swelling, 
and, at a subsequent period, suppuration of the epidermis and 
integument. In the lower part of the canal, where we have the 
density and tenseness of periosteum, the pain may be as severe 
as that from inflammation of the lining of the tympanic cavity, 
or as that occurring in paronychia. 

Prolonged suppuration of the integument, or even suppura- 
tive action that has been of short duration, but violent, may 
produce polypi, or, as I prefer to call them, granulations, in the 
external auditory canal. I have seen several such cases. One, 
that of a lady, was complicated by a precedent inflammation of 
the cavity of the tympanum; but the inflammation of the ex- 
ternal auditory canal was an independent one. Very large gran- 
ulations, or polypi, sprang up in a few days after a poultice had 
been applied. This poultice was ordered by the attending physi- 
cian to relieve the initial pain of an inflammation of the canal, 
such as sometimes occurs from the continued instillation of 
astringents. It was applied for some days through a misunder- 
standing of the damage that might ensue, and very large gran- 
ulations formed. 

Another case occurred in an Irish laborer, whom I saw while 
I held a clinic in the University Medical College. I removed a 
large polypus from the canal, which the patient stated posi- 
tively had occurred in a few days, and that he had never pre- 
viously suffered from disease of the ear. After the treatment 
had progressed for some time, I found that the inflammation 
was confined to the canal and the outer layer of the drum-head, 
and that his statement as to the existence of previous disease 
was probably correct. I could find no cause for the rapid course 
of the inflammation. 

A third case I saw at the Brooklyn Eye and Ear Hospital. 
The trouble in the ear had lasted seven days, and here also there 
was a large polypus. The fourth case was that of a lady whom 
I saw in private practice. She suffered from what she supposes 
to have been an abscess or furuncle of the external meatus. It 
was lanced, and then poultices were applied. I saw her six days 
after. She had used the poultices nearly the whole of the six 
days. I found the canal blocked up by a polypus as large as a 
filbert, growing from the anterior wall of the canal. The final 



DIFFUSE INFLAMMATION. 125 

result of this case in deformity of the auricle, is seen in the en- 
graving on page 113. 

The practitioner need give himself no uneasiness about the 
occurrence of these granulations. As a rule, they subside spon- 
taneously. If not, when well pedunculated they are easily re- 
moved with a curette with sharp edges. 

The microscopic appearances of the growths are identical 
with those of polypi springing from the mucous membrane of 
the cavity of the tympanum, which will be fully discussed in a 
subsequent chapter. 

Although it is anticipating somewhat of what should be said 
under the head of treatment, I will here state that the undoubted 
cause of these growths, in two of the cases just given, was the 
prolonged use of the poultices. Troltsch called attention to the 
fact that poultices produced tedious suppuration ; but I believe 
this is the first iutimation that they cause the sprouting up of 
exuberant granulations in the canal. 

Causes. — The causes of the diffuse form of inflammation are 
various. Irritation of the ear by means of ear-picks, by hair- 
pins, favorite instruments with women ; the instillation of such 
agents as Haarlem oil, Cologne water, camphorated oil, and so 
on, are frequent causes of an inflammation of this part. 

Surf-bathing sometimes is a cause of inflammation of the 
auditory canal and outer layer of the membrana tympani, either 
with or without an inflammation of the middle ear. This is not 
apt to occur among careful, intelligent persons. In surf -bathing 
the bather should take a little pains that the shock of the waves 
does not come upon the side of the head, but in front. When 
the ears are filled with water, they should be carefully dried. 
Prolonged and repeated diving should be avoided, especially by 
those who have sensitive or diseased ears. Caps of oiled silk 
and plugs of oiled cotton are also useful in bathing to those 
whose ears are sensitive to the entrance of salt water. In seri- 
ous cases of aural disease, sea-bathing must be prohibited. This 
subject will be again alluded to in the discussion of diseases of 
the middle ear. 

There is probably some antecedent inflammation of the in- 
tegument which causes a resort to those agents, to relieve the 
troublesome itching sensations. Cold draughts of air are often 
spoken of as causes of inflammation of the outer canal : but such 
influences are more apt to produce an inflammation of the naso- 
pharyngeal space, and through that of the middle ear. In fact. 
the causes of external otitis diffusa seem to be chiefly local, if I 
may so speak ; that is, the disease is caused by mechanical causes 



126 DIFFUSE INFLAMMATION. 

acting locally. There may, however, be an antecedent eczema- 
tous inflammation before the diffuse, non-eruptive form begins. 

A diffuse inflammation of the external auditory canal, quite 
often occurs during the latter part of the course of an acute sup- 
puration of the middle ear, but it usually subsides without spe- 
cial treatment. 

Of late an apparatus, consisting of a very small sponge, at- 
tached to an appropriate handle, and called an aurilave, has been 
devised, and is sold largely by apothecaries as an instrument 
for cleansing the ear. It does a great deal of harm. By its use 
the secretions are packed in the ear, and inflammation of the 
integument or inspissation of the cerumen is very often caused. 

Physicians are often asked if the outer ear should be pro- 
tected from the cold air by a plug of cotton, ear-muffs, or simi- 
lar means. The beginning of aural inflammation is rarely from 
the auditory canal, although the auricle is sometimes frozen 
from exposure to cold. If, however, a person sit in a railway 
carriage which is going very fast, with the ear next to an open 
window, or if the auditory canal and membrana tympani be 
exposed in any similar manner to a draught of air, an inflam- 
mation of the canal and of the tympanic cavity may ensue. But 
when there is no such draught upon the ear, as, for instance, 
when a person is walking or driving in the open air, there is no 
need, unless there is clanger that the auricie will be frost-bitten, 
or there is a strong wind blowing, of using a covering to the 
meatus auditorius any more than to the nostrils. The natural 
curvatures of the canal will prevent a current of air from reach- 
ing the drum-head. This is, however, only true as respects 
healthy ears. In cases of chronic aural catarrh, and in the 
other kinds of troubles of the middle ear, the canals sometimes 
become very sensitive to the cold, and require protection when 
healthy ears do not. When no inconvenience is felt from allow- 
ing the ears to remain uncovered, it is better to leave them 
without protection. The habit of plugging the auditory canals 
with cotton on every slight pretext is a bad one, because it is 
apt to irritate the integument and to cause the ears to be over- 
sensitive, and it may produce dermatitis. As I have said, we 
do not usually get an inflammation of the ear from an exposure 
of the auditory canal, but from such causes as wet feet, an ex- 
posure of the whole surface of the body, and so on. 

Cousins, of London, 1 recommends a little conical cap of vul- 
canite, made of flesh-colored material, as a protector to the audi- 
tory canal from cold and noise, and from water in bathing. This 

1 British Medical Journal, December 31, 1881. 



DIFFUSE INFLAMMATION. 



127 



protector seems to me to be an excellent contrivance for use in 
the cases where protection of this kind is needed. 

There is altogether too much solicitude on the part of moth- 
ers and other persons as to the cleanliness of their children's or 
their own ears. The auricle and the edges of the opening into 
the canal, which are about all that the little finger will reach, 
are the only parts of the organ that require cleansing when the 
ears are in a state of health. Any further manipulations with 
towels, ear-spoons, and so on, are meddlesome, and may become 
dangerous to the health of the canal. 

Treatment. — An attack of diffuse inflammation of the exter- 
nal auditory canal (otitis externa diffusa) in an adult may often 




Fig. 43. 



be cut short by the use of leeches. They should be applied as 
Wilde long ago pointed out, not on the mastoid process, but on 
the tragus, for the reason which Troltsch gives, that in this 
place the vessels which supply the canal and outer layer of 
membrana tympani are most conveniently and surely reached. 
Leeches in this form of disease are not as certain to afford relief, 
however, as when used for an inflammation of the middle ear ; 
when, as we shall see, they exert an almost magical influence, 
so rapid is their effect. In the early stages of the disease, when 
the pain is severe, and suppuration has not yet occurred, but the 
canal is red, swelled, and sensitive, great benefit will be pro- 
duced by scarifications of the cartilaginous wall. This scarifi- 
cation is made with a tenotomy knife. The incisions should be 
from three-fourths to an inch long on the walls of the canal, as 
recommended by Gruber, of Vienna. Warm water should also 
be allowed to run into the ear, by means of the fountain syr- 
inge, the Fayette Taylor douche, Clark's douche, or any similar 



128 



AURAL DOUCHE. 



I 

2?7 



means. When patients are told to apply warm water to the 
ear, unless they are particularly instructed, they will almost in- 
variably use the syringe, thinking that is the way in which the 
water is to be applied ; but what is required is the steady flow 
of warm water upon the part, and this is best attained by means 
of the douche. Patients should be instructed in its use, and es- 
pecially should they be told that, unless the auricle is kept on 
the stretch, so that the walls of the canal are apart, the water 
will not enter the ear. I am thus particular in my advice, be- 
cause, even to this day, I find that many physicians advise that 

warm water be applied to the ear by 
means of the piston syringe instead of 
by a douche. As has been seen in the 
first chapter, Hippocrates advised the 
use of warm water to the ear for the 
relief of pain, but it fell into unde- 
served disuse until the value of its ap- 
plication was reinforced in the minds 
of a profession filled with the idea of 
the virtues of composite "ear-drops." 
The fountain syringe and Taylor's 
douche are more convenient than the 
solid cup making up Clarke's douche, 
and they have pretty generally super- 
seded the latter. 



The Fayette aural douche l consists of two 
siphons, so arranged that the flow starts at the 
same moment in each ; and while one siphon 
conveys the water into the ear the other lifts 
it gently out, without friction or j)ressure upon 
the inflamed tissues. 
In the figure, BG represents the ear-piece, which is made of suitable size and 
shape. Two holes are bored through it, one lying above the other when it is in 
its proper position. On each of the two projections at the larger end, a piece 
of flexible rubber tubing (such as is used for nursing- bottles), about four feet 
long, is fitted. At the small end of the ear-piece the division between the holes 
is cut back about one-eighth of an inch, so that placing the finger over this end 
leaves one continuous passage from the top, A, to the bottom, D. With the 
finger over the small end of the ear-piece, as just described, when water is 
poured into the funnel A, it will flow directly through both tubes, and come out 
at the lower end, D, in the drip-vessel. When all the air has thus been ex- 
cluded and a current established, the funnel A is dropped into the basin or 
pitcher which serves as a reservoir, and a single siphon is formed. The rubber 




Fig. 43. — Fayette Douche. 



tubes are now compressed by the thumb and finger at E, so as to arrest the 



1 Archives of Otology, Vol. VIII., p. 355. 



AURAL DOUCHE. 129 

flow, the finger is removed from the end BC, and the ear-piece is inserted into 
the auditory canal ; then letting go the tubes at E, a double siphon is instantly 
established, AB conveying the water into the ear, and CD carrying it out by 
atmospheric pressure. Thus the resistance and pressure, often painful, of the 
in-coming and out-going currents is avoided, and a small amount of constantly 
changing water, of any desired temperature, is kept in contact with the auditory 
canal and drum-head. Any amount of water desired can be used in one con- 
tinuous bath, without the trouble of refilling the reservoir several times, as is 
so often required in using the fountain syringe. 

Dr. Taylor invented this douche while under my care, and he 
found it, as have many of my patients since, a pleasanter method 
of using a warm douche to the ear than the fountain syringe. 

Objections are made by some writers to the continuous use of 
warm water in inflammations of the canal, but my faith remains 
unshaken in the great value of the warm or even hot douche in 
the vast majority of cases of acute inflammation of the canal 
and tympanum, and I recommend it to the profession in great 
confidence that only in exceptional cases will they be disap- 
pointed with its effects. There are a few patients who never find 
it pleasant, and some who can bear it only for a time, but most 
patients, even young children, who at first object to its use, soon 
find in the warm douche a source of relief from pain in acute 
inflammations of the canal or middle ear. 

In the absence of the cup, a bit of rubber tubing and an ordi- 
nary bowl, by the application of the principle of the siphon, will 
make an efficient and simple douche. 

The value of the aural douche is by no means limited to 
cases of inflammation of the outer portions of the ear. In acute 
inflammations and chronic suppurations of the middle ear, it 
becomes a very valuable means of alleviating pain and of 
cleansing the ear. For the latter purpose it is especially valu- 
able among children. 

If the use of the leeches, the employment of scarification, 
and the warm douche do not wholly subdue the pain— which is 
quite unlikely — a small flax-seed poultice may be applied in the 
meatus, over the mastoid, and in front of the auricle ; but the ear 
should not be covered by a large poultice, as is often done : such 
poultices relax the tissue to so great an extent that granulations 
or polypi are apt to spring up from the softened and loosened 
tissue, as we have seen in the cases that I have detailed. A 
poultice should never be applied to or on the ear for more than 
a few hours. They are almost as dangerous a remedy in aural 
as in ophthalmic practice, where they have caused the loss of 
many eyes. 

At night the ear should be kept warm by wrapping- it in eot- 
9 



130 DIFFUSE INFLAMMATION. 

ton, and the patient should lie on a pillow that is warmed from 
beneath, by means of a rubber bag filled with hot water, or some 
similar contrivance. A plug of cotton saturated in glycerine or 
smeared with diachylon ointment, is also of value in subacute 
cases. By attention to these details much suffering will be 
spared the patient, and the course of the affection will be short- 
ened. In addition to the local treatment, it will sometimes be 
necessary, although not often, to give one of the preparations 
of morphine, or a dose of chloral internally. I have not found 
much advantage from the addition of narcotics to the warm 
water instillations, although there may be some benefit from 
their use. 

In severe cases of inflammation of the external ear occur- 
ring in adults, I have lately, at the suggestion of Dr. W. S. Ely, 
of Kochester, used at bed-time, to be repeated every two hours, 
if necessary, a formula, embracing sulphate of morphia, hydrate 
of chloral, and bromide of sodium in each dose, with the effect of 
securing sound sleep in cases where other means for the relief of 
pain did not enable the patient to get but snatches of repose. The 
wit of the medical attendant will sometimes be taxed to its ut- 
most in order to secure rest for his patient suffering from acute 
inflammation of the auditory canal. Indeed, I find it generally 
easier to secure prompt relief from a pain in the ear, arising 
from an inflammation of the tympanic cavity and mastoid cells 
than from a diffuse or furuncular inflammation of the canal. 
Yet, in all the anxiety to relieve pain, the physician may derive 
much consolation from the knowledge that the patient will ulti- 
mately recover with perfect hearing, if the auditory canal and 
drum-head be the only parts seriously involved. 

The popular remedies for ear-ache, dependent upon whatever 
cause, are usually sweet-oil and laudanum, molasses, Haarlem 
oil, glycerine, and a roasted onion. The oil, laudanum, and 
molasses are tolerably efficient ; but although they are useful in 
their property of stilling pain, they are far inferior to the leeches, 
scarification, and warm water. I have seen children, who had 
been suffering from severe pain in the ear, drop off to sleep in a 
few moments after a tablespoonful of warm water was poured 
into the ear ; and yet I am very sorry to say that there are some 
rare cases where warm water seems to aggravate the pain ; the 
leeches sometimes also fail us in the disease now under discussion. 

The onion acts just as the conical flax-seed poultice, and may 
be resorted to if the warm water fails, and leeches are not to be 
had. Haarlem oil, and all similar stimulating applications, do 
nothing but harm, and increase the sufferings of the distressed 
patient. The laity resort to such applications, and submit for 



DIFFUSE INFLAMMATION. 131 

days to pain in the ear, without going to a physician, because 
they have been taught by sad experience that doctors pay very 
little attention to an ear-ache — and yet what pain is worse ? 
Warm vapor of any kind, the vapor of chloroform, the smoke 
from a cigar, for example, is very grateful to an inflamed audi- 
tory canal or membrana tympani; and a steam nebulizer be- 
comes at some times a very useful adjuvant in treatment of 
acute aural inflammations. Sometimes children, who awake at 
night with ear-ache, may be quieted by breathing slowly into 
the auditory canal. 

Some practitioners are in the habit of indiscriminately advis- 
ing blisters behind the ear in all forms of aural disease, whether 
acute or chronic. I formerly supposed that they were not of 
much value except in chronic cases, but I am convinced that 
harsh as is the remedy apparently, it is sometimes very efficient. 
The following case is one almost in point, and I do not now 
hesitate to advise blisters in severe inflammations of the canal 
as well as those of the middle ear. 

I lately saw a case in consultation with Dr. S. Beach Jones, 
of acute catarrh of the middle ear, occurring in the course of 
measles, in a young boy, for which the mother had applied a 
blister over each mastoid, and apparently with good effect. In 
these days of pleasant remedies this seems harsh treatment, but 
the mother and the boy seemed satisfied with what Dr. Jones 
and I would have hesitated to recommend. I only object to blis- 
ters because I think better results may be attained with milder 
means. Their efficacy can hardly be doubted in many cases. 
Speedy relief from the severe pain of otitis is as imperative as in 
peritonitis or iritis, and I have dwelt on the various remedies at 
some length, in order that the practitioner may be at no loss 
for some agent that will cut short the inflammatory action. I 
will tabulate the remedies in the order that I consider them 
valuable : 1. Leeches ; 2. Warm douche ; 3. Blisters ; 4. Scarifica- 
tion ; 5. Conical poultice in the canal ; 6. Steam or warm vapor ; 
7. Narcotics. 

Dr. A. D. Williams recommends the use of a solution of a 
sulphate of atropia, two to four grains to the ounce, which is 
dropped into the auditory canal as a remedy for the relief of the 
pain from aural inflammation. I have found this an uncertain 
remedy, but in some cases it quiets pain. I think, however, 
that it is more apt to be of use in the rare eases of neuralgia of 
the ear — cases where there is pain without the usual signs of in- 
flammation — than in external otitis. Knapp 1 reports a ease of 



Archives of Otology. Vol. XI.. p. 83, 



132 



SYRINGING THE EAR. 



transient poisoning from the instillation of a few drops of atropia 
in the auditory canal. The patient was a woman of twenty-five, 
in good health. Four hours and a half after dropping in a half 
per cent, solution of sulphate of atropia the hands of the patient 
began to swell and become stiff, the face became scarlet, her 
throat dry and so forth. The symptoms abated in about five 
hours. The pain in the ear was relieved and a subsequent in- 
stillation of a weaker solution had no evil effect. The auditory 




Fig. 44.— Syringe for the Ear. 

canal and membrana tympani were free from excoriation and 
ulcer. We sometimes see this extreme susceptibility to atropia, 
but it is so rare, that I do not think it is to be regarded if it 
becomes necessary to use it for the relief of pain. I wish I 
could say, that it had often proved an efficient agent in my hands 
for the relief of the pain of otitis. 

Most adult patients go about while suffering from external 
diffuse otitis. During the more acute stages it would be better 




//' 



Fig. 45. — Reservoir Syringe. 



to keep them in-doors and in bed. If this can be accomplished, 
the use of diaphoretics will aid the local treatment. 

If, in spite of our efforts, suppuration is once fairly estab- 
lished, or if the disease has advanced to this point when first 
seen by the practitioner, we must endeavor to limit the suppu- 
ration. To this end thorough cleansing of the ears is necessary. 
This is best accomplished by syringing — a simple procedure, but 
one which many physicians are unable to carry out efficiently 



SYRINGING- THE EAR. 



133 



and with neatness. The appliances necessary for a thorough 
syringing of the ear are, first, a good syringe. I think the small 
piston syringe is the best, and I do not advise the common soft 
rubber enema syringe called "Davidson's" in this country. 
The glass syringes are of no use whatever. 

Where patients are likely to need an aural syringe for a 
long time, it is better to advise them to get one made of brass or 
German silver. The hard-rubber syringes are carelessly made 
as a rule. Indeed, the practitioner will find it difficult to secure 
a good syringe without taking some pains, for even the metal 




Fig. 46. —Method of Syringing the Ear. 



ones sold by the instrument manufacturers of New York are often 
very carelessly made. Luer, of Paris, sells a reservoir syringe, 
represented in Fig. 45, which is exceedingly useful, especially 
in hospital practice, where much use of a syringe is required. 

Then we need a bowl — a small one, not a large wash-bowl, 
but one such as is used as a finger-bowl— being thin and easily 
held — and a receptacle for the warm water which is to be used 
in the syringing process. No towels or napkins are needed 
about the neck, to prevent injury from the water ; no assistant 
beside the patient is required, if he be an adult, and if the proee- 



134 SYRINGING THE EAR. 

dure be carried out as will be described. The patient being 
seated, holds the bowl well under the auricle, in the hollow just 
under the lobe, keeping the head perfectly straight, and using 
both hands to steady the vessel. The surgeon should thoroughly 
straighten the auditory canal with the left hand, and placing the 
nozzle of the syringe well into the meatus, direct the stream 
with the right, down to the membrana tympani. It is well to 
prepare the patient for the shock of the water, by allowing a 
part of the first syringef ul to pass into the concha, and not into 
the canal. 

It will be seen that no patient is capable of thoroughly 
syringing his own ear, and that no person who has not been 
taught the simple process will be able to accomplish the object 
for which syringing is undertaken, that is, the cleansing of the 
auditory canal and the outer surface of the membrana tympani, 
and, if it be perforated, the tympanic cavity. Notwithstanding 
these facts, patients suffering from an ulcerative process in the 
ear, and who require the daily removal of the pus as an essen- 
tial to recovery, are often sent away without other instruction 
than the advice to syringe the ear. It is almost as difficult for a 
person to properly syringe his own ear as to cauterize his own 
palpebral conjunctiva. We certainly should never think of 
leaving the latter manipulation to any but a person who had 
been taught to manage it properly. 

The ear affected with chronic external otitis should be 
syringed from one to three times daily while the secretion is at 
its height. It should afterward be carefully dried by means of 
absorbent cotton, upon a cotton-holder. The cotton-holder may 
be made of wood or metal. If the end be roughened, the cotton 
may be more easily kept upon it. Neither syringing nor cleans- 
ing with a cotton-holder need be at all a painful process ; it must 
be done gently, and this direction applies to all the manipulations 
upon the ear. A wise patient will prefer to leave his case to 
nature and to his own care, than to trust his ear to a physician 
who handles it roughly. As I have before said, in discussing 
another subject, one of the best means of becoming a gentle and 
successful aural surgeon is to submit one's self to the use of the 
Eustachian catheter, the speculum, syringe, and cotton-holder 
before beginning to practise upon patients. 

The agents which may be used in checking ulceration in the 
canal are numerous. I perfer solutions of nitrate of silver, of 
alum, and of the sulphates of zinc and copper, to the others. The 
nitrate of silver I use in strong solutions, from 20 to 40 grains to 
the ounce, pencilled over the parts ; the sulphates and the alum 
in solutions of from 1 to 4 grains to the ounce, instilled into the 



CHRONIC SUPPURATION OF CANAL. 135 

ear. The choice of the astringent is, however, much less im- 
portant than the thorough removal of the pus, which should be 
done at least three times a week, and, if possible, daily, by the 
physician himself. The patient or his attendants should use 
the syringe from once to four times a day, according to circum- 
stances. 

What may be done for a neglected suppuration of the audi- 
tory canal, by the mere daily removal of the pus and the appli- 
cation of a caustic or astringent, however many alteratives 
and other constitutional remedies may have been taken in vain, 
is sometimes marvellous. Astringent or absorbent powders are 
more applicable to diseases of the middle ear than to those of the 
canal. 

Indeed, careful and thorough cleansing, without the subse- 
quent use of astringents, will often effect a cure. It is now my 
habit to delay the use of astringents until I am sure that no prog- 
ress in a case is being made without them. In some cases I am 
never compelled to resort to any other treatment. This is some- 
times overlooked by those who attach much importance to the 
use of constitutional remedies or internal medication in the 
treatment of localized suppurations of the ear. A suppuration of 
the external auditory canal, like the same disease in the middle 
ear, has a natural course, which often needs mere guidance to 
lead it to a successful termination. To study this course is more 
important for the young practitioner than to learn what drugs 
are said to be of service in certain diseases. 

If the pain be severe and the tension evidently marked, the 
proper treatment is incision. A narrow knife is a very good 
one for the operation. The incision should be deep and free. In 
very delicate and sensitive patients it may be well to put the 
patient under the primary anaesthetic effect of sulphuric ether 
before making the cut. This is done by causing the patient 
to inhale the fumes of the ether in the usual way, holding up 
the arm while inhaling. When the arm drops, usually in 
twenty seconds, the incision may be made without causing pain, 
while not enough ether will have been taken to cause nausea 
or vomiting or other serious inconvenience. In place of the 
ether patients may take a dose of brandy or whiskey before sub- 
mitting to this painful operation. I dare not recommend any 
other anaesthetic than sulphuric ether, even after hearing all 
that is said for chloroform, bromide of ethyl, and the rest. 

In the writings of Dr. Buck 1 and others, some stress is laid 
upon what is termed "desquamative inflammation" of the ex- 

1 Diseases of the Ear, p. 80 ; also Medical Record, Deoember 15, IS??. 



136 DESQUAMATIVE INFLAMMATION. 

ternal auditory canal. A separate form of diffuse inflammation 
is made by this method of naming diseases, but I continue to 
regard the desquamative variety as merely one of the very com- 
mon stages of diffuse inflammation. A certain amount of des- 
quamation must occur in any severe inflammation of the integu- 
ment of the canal. The kind of desquamation described by Buck, 
I have often observed in cases of aspergillus of the canal, and 
also after eczema and impacted cerumen. I think bichloride of 
mercury, gr. T V to gr. I ad aq. § j., and nitrate of silver and pure al- 
cohol, particularly well adapted for the treatment of these cases. 
The practitioner should always be on his guard, lest he mis- 
take a chronic suppuration in the middle ear for one of the 
auditory canal, with an intact membrana tympani. It will be 
seen by the statistics in the chapter on the former disease, that 
a long-continued suppuration in the ear usually has its origin, 
not in the canal or outer layer of the drum-head, but in the 
cavity of the tympanum, whence it advances and perforates the 
membrana tympani. Chronic suppuration in the external audi- 
tory canal, contrary to what has often been written, and con- 
trary to the opinion of most practitioners with whom I have 
conversed on this subject, is, judging from my experience, a rare 
disease, When it does exist, it is almost always curable, if prop- 
erly treated, by the free use of the warm douche, astringents, and 
leeches, if need be. 



CIRCUMSCRIBED INFLAMMATION, OR FURUNCLES OF THE EXTERNAL 

AUDITORY CANAL. 

By circumscribed inflammation occurring in this part we 
simply mean furuncles. They generally arise in connection 
with the existence of furuncles in other parts of the body, and 
are, like them, very painful. They also produce impairment of 
the hearing by mechanically closing the auditory canal. Tinni- 
tus aurium — noise in the ears — a symptom which is apt to be very 
troublesome in almost all other aural affections, is not generally 
present when furuncular inflammation exists. It may be, how- 
ever, after the pus from the boil has been evacuated, and some 
of it, perhaps, remains in the canal and presses upon the mem- 
brana tympani, and through it upon the ossicula auditus and 
auditory nerve. The tinnitus is absent in the early stages, be- 
cause there is no pressure exerted upon the drum-head by a cir- 
cumscribed swelling of the canal. 

There will be no difficulty in the diagnosis if the ear be ex- 
amined by means of the otoscope. One or more circumscribed 
swellings are found in the calibre of the canal. Their usual 



FURUNCLES. 137 

situation is a point near the tragus, on the anterior wall, and 
we may have two or more at a time. 

The proper treatment is to make an incision at as early a 
period as possible, and then to continuously apply warm water, 
giving the ear an uninterrupted warm bath, as it were. It 
makes no difference whether pus or blood be evacuated by the 
incision. The relief following is generally immediate in either 
case. If the pus be deeply situated it will be better to make 
the incision with a scalpel, cutting downward. If it be near the 
surface a bistoury may be used, and the cut made from below 
upward. The ear should be syringed with warm water after the 
hemorrhage has ceased, and carefully dried with the cotton- 
holder, or the impairment of hearing and sensations of fulness 
will be greater than before the opening was made. 

After the furuncle is opened, and the pain caused by it has 
disappeared, it is well to smear the passage with ointment, in 
order to hasten the softening of the indurated tissue surround- 
ing the furuncle, but as long as pain continues the use of warm 
water should be persisted in by means of the aural douche. The 
thorough cleansing will usually relieve the impairment of hear- 
ing caused by the swelling and closure of the canal, while the 
incision and douche will cut short the pain. Each new furuncle 
is of course to be treated in the same way. Sometimes steam, 
conducted into the canal from any suitable vessel, is of great 
comfort to the inflamed part. 

Leeches are not usually of much service in furuncular in- 
flammations of the canal. Warm water is not always well borne, 
but in the majority of cases it is of the greatest value in palliat- 
ing this troublesome affection. In this respect I cannot agree 
with Politzer, 1 who thinks the warm douche gives rise to fresh 
eruptions. After all my experience in this painful, although 
not dangerous affection, I still hold to the knife, warm water, 
small poultices in the meatus and in front and behind the 
auricle, and the internal administration of narcotics, as being, 
on the whole, the best means of treatment. 

Dr. Buck 2 thinks that we cannot expect the same relief from 
an incision into the auditory canal as that made in paronychia, 
because " a comparatively unyielding cylinder of cartilage sur- 
rounds the inflamed tissues and renders relaxation of the parts 
almost an impossibility/' I think there will be no difficulty in 
relaxing the tense point, if the incision be made through it. In 
order to secure this, the surgeon should feel about very care- 
fully with a probe for the most sensitive part before operating. 



1 Text-book, Cassel's translation, p. GOO. * Text-book, \\ 71. 



138 FURUNCLES— SULPHIDE OF CALCIUM. 

If needful, he should make two incisions at different points and 
be sure to make them deep enough. If the inflammation be not 
plainly circumscribed, the disease will have passed over the 
narrow boundary line between this and diffuse inflammation. 
If incisions are then useful, several must of necessity be made. 
A plug of glycerine, or diachylon ointment, or a small, finger- 
shaped, flax-seed poultice is of much service after the incision. 

Buck and Politzer have seen furuncles of the ear occurring 
in persons otherwise in good health, but, as I have already said, 
I consider auditory furunculosis to be an indication of a low state 
of the system, and I do not think I have ever seen a primary 
affection of this kind in a thoroughly well person. When such 
cases come to me, I invariably find a necessity for constitutional 
treatment. It is not unusual to observe a circumscribed inflam- 
mation of the canal after a tedious or severe suppuration of the 
middle ear, or rather while it is in progress, but this I consider 
an entirely distinct affection from that which is now being dis- 
cussed. 

Ringer, 1 in an article upon the sulphides, in his work on 
therapeutics, says that the sulphides appear to him to have the 
property of preventing and arresting suppuration. He thinks 
that in an "inflammation threatening to end in suppuration 
they reduce the inflammation and avert the formation of pus." 
Based upon Ringer's statements many cases of suppuration of 
the various parts of the ear have beent reated by Sexton, Bacon, 2 
Rupp, 3 and others, and reports of the results made in special 
and general journals. These writers are loud in their praise of 
the value of the drug when used to prevent or limit suppuration 
in the ear. The Therapeutical Society of New York reported 
on the whole favorably upon the results of the drug in suppura- 
tions. I have given the sulphide of calcium a fair trial, and I 
have never seen any benefit whatever from its use. I have also 
carefully studied the reports of the cases furnished by the vari- 
ous authorities just quoted, and I fail to find any evidence in 
them that the favorable results are any different from those oc- 
curring in similar cases when no drug was used internally. It is 
the habit of those who use the sulphide of calcium, as will be 
seen by a study of their cases, to employ all the local means that 
are used by surgeons in treating suppurations. It is claimed that 
the use of the knife is avoided by the abortive power of the drug. 



1 A Hand-book of Therapeutics, p. 137. Tenth edition. New York, 1883. 

2 Archives of Otology, Vol. XV., p. 122. 

3 American Journal of Otology, Vol. IV., p. 194. Transactions of the American 
Otological Society, Vol. HI., Part II., p. 181. 



FURUNCLES— CAUSES. 139 

But all of us see many cases subside without incisions and when 
no internal medication is employed. Sexton ' says, " In some in- 
stances I rely entirely on this remedy (calcium sulphide) in the 
treatment of inflammation in the ear ; but free incisions are in 
some instances of course not to be omitted." 

The question of the value of internal medication is one noto- 
riously hard to solve ; but certain it is, however, that calcium 
sulphide has not yet obtained a firm hold upon the profession as 
a means of aborting or checking suppuration. I have not been 
able to satisfy myself that we as yet have any specific for aural 
inflammations of a suppurative character. 

We shall probably not be done with the case when one fur- 
uncle has been evacuated, and has healed ; for here, just as in 
other parts of the body, one boil is apt to follow another in rapid 
succession. 

Causes. — This brings us to consider the cause of this affec- 
tion. I do not think I ever saw a furuncular inflammation of 
the external auditory canal in a patient who was in other respects 
in a good physiological condition. It seems to be the evidence 
of a wrong state of the system of some kind. 

Furuncles are very apt to occur in anaemic persons. I have 
seen several cases where they were troublesome after parturi- 
tion, during which the system had been much exhausted, and 
perhaps the patient had not been under the most judicious man- 
agement as regards the diet. When iron was administered, and 
nourishing diet substituted for slops, the boils ceased to recur. 

Dr. Lowenburg, 2 of Paris, examined furuncles of the auditory 
canal, prior to their opening, before the pus formed in them had 
come into contact with the atmosphere. The pus freshly obtained 
was cultivated in beef soup or diluted extract of beef. The coc- 
cus of furuncle was abundantly produced by these experiments. 
Lowenburg regards these micro-organisms as the cause of fur- 
uncular inflammation. Micrococci suspended in air and water 
get into the canal, and passing into the glandular structure set 
up inflammation. 

His exact language is, "I think that every furuncle is an in- 
vasion of a particular species of microbes, which exist in the air 
and in water, and which are multiplied under the influence of the 
decomposition of certain substances. In consequence of some 
circumstances still unknown, these microzotes (microzoaires) 
enter a pilo-sebaceous follicle ; they then fructify and excite the 

1 American Journal of Otology, Vol. I. 

2 Archives of Otology, Vol. X.. p, 000. 



140 LOWENBURG ON FURUNCLES. 

characteristic f uruncular inflammation." Lowenburg then goes 
on to show that once having entered the follicle, the micrococci 
propagate themselves by what he styles "auto-infection." The 
parasitic origin of furuncles is further substantiated, in Lowen- 
burg's opinion, by the fact that they chiefly occur in parts ex- 
posed to the air, the face, the hands, the neck. "The first aural 
furuncle," he continues, "is found at the entrance of the canal, 
the succeeding ones affect the deeper parts, and the predilection 
of furuncle for those who handle rags." 

The contagiousness of furuncle is also insisted upon by this 
writer, and he records a case where a strong and healthy man 
suffered from one in the ear after his wife had been affected by 
one. The furuncle in the man was in the left ear, in a cor- 
responding situation to one in the right ear of the wife. Lowen- 
burg treats furuncle by an incision, under local anaesthesia by 
the cold spray. The part is then kept moist with solutions of 
thymic or boric acid. Weber-Liel injects their tissue with a 
solution of phenic acid. Lowenburg considers that poultices 
favor the formation of micrococci, and that they should not 
therefore be used in the treatment of furuncles in the ear. These 
views of the parasitic origin of furuncles are entitled to great 
respect in the present condition of the mind of the profession, in 
regard to the parasitic origin of disease, yet I cannot regard 
it as yet settled that micrococci are not consequences rather 
than causes of the diseases thought to be produced by them. 
Certain it is, that there must be in the general system some 
preparation for the invasion of these dangerous micro-organisms, 
or in the frequency of furuncle, contagion would be much more 
common. If furuncles be contagious, common experience shows 
that they are only so to a limited degree. I have never observed 
that they passed through families. Lowenburg's one case seems 
to me slender evidence upon which to base such a theory. Then 
as regards the value of thymic and boric acid as antiseptics, I 
am, from experience in their use, and from the results of recent 
experiments, extremely skeptical. I believe that water is quite 
as efficacious as many of the so-called antiseptics. When a 
question such as the great one of the septic origin of disease is 
being discussed, I believe that the great truth that must be 
somewhere in this subject will be the sooner brought out the 
more frank and critical are the analyses of the theories and ex- 
periments that are being constantly set forth. 1 

1 Congres Periodiqne international d'otologie. 2 e Session. Milan, 1880 ; Trieste, 
Imprimerie G. Caprin, 1882. 



CHAPTER VI 

PAEASITIC INFLAMMATION OF THE EXTEENAL AUDITORY CANAL 
—SYPHILITIC ULCERS AND CONDYLOMATA— CONTRACTIONS- 
DIPHTHERIA— SARCOMA— C ARIES. 

History of the Discovery of the Growth of Aspergillus in the External Auditory Canal. — 
Varieties of Vegetable Fungi found in the Ear. — Cases. — Syphilitic Ulcers and 
Condylomata. — Narrowing and Closure of the Canal. — Diphtheritic Inflamma- 
tion. — Sarcoma. — Caries of the Canal. 

It is about sixteen years since the profession became generally 
aware of the fact that vegetable fungi were germinated in the 
auditory canal, and that they caused or aggravated inflamma- 
tions of this part and of the surface of the membrana tympani. 
By the publications of Professor Schwartze, of Halle, Dr. Wre- 
den, of St. Petersburg, and many others whose names will be 
quoted in this chapter, this fact has now become well known, 
and has enabled us to more clearly understand and more suc- 
cessfully treat certain cases of otitis externa. 

The history of the growth of the aspergillus fungus, as well 
as that of the other vegetable parasites that have been found in 
the ear, is interesting and important, and a full account of it 
will, I am sure, be welcomed by the reader. 

In 1867, Schwartze 1 reported a case of inflammation of the 
auditory canal, in which the aspergillus fungus was found. 
Professor J. Vogel made the microscopic examination that set- 
tled the fact, and he called Schwartze's attention to two cases 
which had been previously reported ; one by Mayer, in Midler's 
Archiv, p. 401, 1844, and one by Pacini, quoted by Kuchen- 
meister, in his work on "Parasites," published in Leipzig in 
1855. In both these cases the fungus was a species of asper- 
gillus. 

Mayer's case was peculiar. The fungus occurred in the ear 
of a child, having what he called scrofulous otorrluva, and the 
parasite was contained in round and oval cysts, oi' the size of a 
cherry-pit. The walls of the cysts were fibrous, filamentous. 



Archiv fur Ohrenheilkunde, Bd. 



142 PAKASITIC INFLAMMATION. 

white in color externally, while within they were hollow, green- 
ish, and granular. 

Pacini's case was like those that have since been observed : 

A boy of fourteen years came from a sea-bath, and complained that water 
remained in his ear. Itching and painful sensations ensued, and at last nearly 
complete deafness. In the auditory canal small transparent vesicles were seen. 
Two weeks after a whitish membrane was found on the walls. It was removed 
by syringing with warm water ; but it soon returned. The microscopic exami- 
nation revealed the presence of a fungus. The parasite was removed by the 
injection of a solution of acetate of lead, of the strength of two grains to the 
ounce of water. 

Dr. Eobert Wreden - reported six cases of the growth of the 
aspergillus fungus the year after Schwartze's case was pub- 
lished. He gave the name of myringomykosis to the disease 
caused by the fungus. He subsequently added eight to these, 
and published the whole, with a very complete account of the 
appearance of the fungus, in a monograph. 2 

Soon after the publication of Schwartze's and Wreden's cases 
others were reported by Orne Green, 3 of Boston, C. J. Blake, 
Knapp, and by myself 4 and others. Indeed, the occurrence of 
such a fungus in an inflamed ear is now a well-recognized fact, 
for which we are indebted to Schwartze. 

The literature of vegetable fungus in the human ear has be- 
come very large since the publication of the cases of Schwartze, 
"Wreden, and of the observers immediately after them, but in 
very few directions has it increased the knowledge given us by 
Wreden s first brochure. 

Wreden 5 and Swan M. Burnett, 6 however, have lately reported cases which 
furnish pretty strong evidence that the fungus known as otomyces purpureus 
may be found in the auditory canal without being a part of the aspergillus nigri- 
cans, or, as Wreden had thought, the highest form (most developed) of the spe- 
cific aural fungus. In other words, a distinct variety of vegetable fungus has 
been found in the ear. In Burnett's case a mixture of tincture of opium, sweet 
oil, and glycerine had been poured into the auditory canal to relieve the symp- 
toms of what was called psoriasis. The ear became painful after this, and on 
examination Dr. Burnett found a plug of dark-red, quite consistent material. 
An examination with the microscope showed this to be a fungoid growth. In 
"Wreden's case evidences that the growth was one of the highest forms of devel- 



1 Archiv fiir Ohrenheilkunde, Bd. III. , p. 1. 

2 Die Myringomykosis aspergillina. St. Petersburg. 

3 Transactions of the American Otological Society, 1869. 

4 American Journal of the Medical Sciences, January, 1870. 

5 Wreden: Archives of Ophthalmology and Otology, Vol. IV., No. 1. 

6 Archives of Otology, Vol. X., p. 319. 



CAUSES OF PARASITIC INFLAMMATION. 143 

opment of aspergillus nigricans were found, but not so in Burnett's. He found 
in his specimens at no stage of their growth nothing but otomyces purpureus. 
Professor Farlow, of Harvard University, thought the specimen was probably 
not a variety of aspergillus, as Wreden supposed, in regard to his case. 

Causes. — In order that we may correctly understand the na- 
ture of parasitic otitis, it should be remembered that it is not a 
primary disease, but a consequence of a diffuse otitis, which 
may have been of such a mild character as scarcely to have at- 
tracted the attention of a patient, especially if it occur in one 
who is taught to believe, as most patients are, that an aural dis- 
ease will "wear away" of itself, or, at any rate, that medical 
assistance will be of no avail for it. 

The disease, that is the formation and development of a vege- 
table fungous growth, may result from an eczema, or, as in Bur- 
nett's case, just quoted, from a psoriasis, or probably from any 
form of inflammation of the canal, especially if oils have been 
dropped into it. I have not yet seen a case of otitis parasitica 
in which I thought there was any evidence to show that the ear 
was sound just before the growth occurred. The soil must first 
be prepared by a loosening of the epidermis before the fungus 
will grow. 

The origin of the disease may generally be traced back to an 
inflammatory affection of the canal, one that has softened the 
tissues. Added to this, oils, generally the common sweet oil, 
have been used to combat the inflammation. Given these two 
factors, the inflammatory basis and the oils, and the propagation 
of the aspergillus fungus may be pretty accurately predicted. 
One of the best reasons against the use of oils in the canal is 
their liability to cause the growth of a fungus. 

The fungus is actually a mould, such as clings to damp walls 
and adheres to bread that is not kept thoroughly dry. As we 
should expect, the habits of the Russians, living as they are 
almost compelled to, in badly ventilated rooms during the long 
winter, are very favorable to the production of aspergillus. 

There is hardly a doubt that these cases of vegetable fungous 
growths in the ear were formerly mistaken for impacted ceru- 
men or eczema, and otitis externa diffusa. Since my attention 
has been called to the subject, I recall two eases of very obstinate 
inflammation of the auditory canal, which I now believe were 
cases of the growth of vegetable parasites in the part. It is an 
interesting fact, that they both recovered from the affection 
without any use of the specific parasiticides. 

The wax is thought by 0. H. Burnett to be a protection against 
aspergillus, but I regard it rather as an incident in the formation 



144 PARASITIC INFLAMMATION. 

of the fungus, for I think it is pretty well established that ceru- 
men never becomes hardened or impacted in a healthy auditory 
canal. 

While preparing these pages for the press, I found a growth 
of aspergillus at the bottom of an auditory canal that was filled 
with impacted cerumen. 

Symptoms. — The subjective symptoms of the growth of a 
vegetable fungus in the ear are very similar to those from in- 
spissated cerumen. There is a sensation of fulness in the ear, 
with tinnitus aurium, vertigo, impairment of hearing, and pain. 

As is well known, pain is not a common symptom of inspis- 
sated cerumen, although it does occur. Pain is, however, usually 
one of the symptoms of otitis parasitica. It is not usually, how- 
ever, the severe pain of a furuncle, or of acute catarrh of the 
middle ear, but it is a dull, heavy sensation in the ear. 

The objective symptoms consist in the adherence to the walls 
of the canal and to the outer surface of the membrana tympani 
of whitish, or blackish, or even reddish flakes, that may be read- 
ily mistaken for simple epidermis or hard wax. Sometimes these 
flakes or casts block up the whole passage. They cannot be re- 
moved by a syringe ; but the angular forceps, which should only 
be used under a good illumination by means of the otoscope, are 
required to detach them. When the casts are removed the tissue 
beneath is found to be reddened and tender, and in a very few 
hours the growth will be found to be reproduced. 

The microscope must be called in to make the diagnosis cer- 
tain. The appearance of the growth, as seen by the aid of this 
instrument, will soon be detailed. The practitioner who has once 
carefully observed the objective evidences of a vegetable fungus 
will, however, not be apt to fail to recognize it in a subsequent 
case without a microscope. 

The varieties of vegetable parasites that may be found in the 
ear, and which there cause or increase inflammation, are 

( flavus, 
I. Aspergillus < glaucus, 

( nigricans. 
II. Penicillium glaucum. 

III. Graphium pencilloides. 

IV. Trichothecium roseum. 
V. Otomyces purpureus. 

The aspergillus fungus, which, in one of its varieties, is the 
parasite most commonly found in the ear, seems to have a pecu- 



ASPERGILLUS. 



145 



liar affinity for a diseased auditory canal and membrana tym- 
pani, and to be found almost exclusively on this part of the body. 
Dr. William H. Draper, of this city, has, however, observed one 
case of the growth of the aspergillus fungus on the inner side of 
the thigh, and it afterward appeared in the auditory canal. 
Wreden was not able to find any penicillium fungus in his cases, 
but Blake ' reports a case in which, on the second attack of otitis 
parasitica, specimens of bastard penicillium were found. 

Dr. Hassenstein, 2 of Gotha, has observed one case in which a 
patient suffering from the usual symptoms of aural catarrh was 
found to have a yellowish-green secretion upon the membrana 
tympani. This secretion continued for some ten days, in spite 
of treatment, and there was considerable redness, swelling, and 
pain in the auditory canal and drum-head. 




Fig. 47. — Aspergillus Nigricans (220 diameters). «, Mycelium fibre ; &, fruit-bearing 
fibre ; c, naked sporangium ; d, sporangium covered with basidia only ; e, more mature spo- 
rangium ; i, spores in a state of germination. 

This secretion was found to contain three varieties of vege- 
table fungi, as an examination by Professor Hallier. of Jena, 
showed : 1. Aspergillus glaucus. 2. Stemphylium, which was 
very like stemphylium polomorphum belonging to the asper- 
gillus. 3. Graphium pencilloides. Dr. Hallier was unable to say 
whether the second variety sprang directly from the aspergillus 
or not. The graphium pencilloides, of which an accurate botan- 
ical description is given in the article from which I am quoting. 
occurs in nature on wood, especially on elder-wood. 



1 Transactions of the American Otological Society, fourth year, 1871, 
8 Archiv ftir Ohrenheilkun.de, Bd. IV., p. 1(54. 
10 



146 



PARASITIC INFLAMMATION. 



Dr. F. Steudener, 1 of Halle, describes another form of fungus 
which occurs in the ear, Trichothecium roseum. The evidence 
on this point is not quite conclusive, however, for Professor de 
Barry, to whom Dr. S. showed the specimen, said it resembled 
this fungus, although it could not be thoroughly examined, the 
specimen having been injured. Dr. Steudener then cultivated 
the actual trichothecium fungus upon some epidermis, and in- 
asmuch as the spores and mycelium resembled those in the 
fungus removed from the ear, he thought himself justified in 
assuming that the latter were actually those of the trichothecium 
roseum. The evidence is therefore not quite positive as to the 
nature of the fungus. 

The different varieties of the aspergillus fungus are by far the 
most common kinds of vegetable parasites that have been found 
in the ear, although, now that attention has been turned to this 
subject, others have been found. 




Fig. 48. — Aspergillus Flavescens (220 diameters). <z. Mycelium fibre; b, fruit-bearing fibre; 
c, sporangium-bearing spores upon the basidia ; g, basidia, showing constriction ' preparatory 
to the separation of spores ; k, epithelium. 

The first two of the accompanying drawings of the aspergillus 
were made by my friend, the late Dr. William B. Lewis, 2 for an 
article by myself upon the subject, from specimens of cases 
occurring in my practice. The third engraving (Fig. 48) repre- 
sents another specimen from the same source, which was drawn 
by Dr. Charles S. Bull. Dr. Lewis describes the fungus as of 
three essential parts : 

First, the mycelium, a dense network or pseudo-membrane of 
delicate fibres, which form the groundwork or roots, as it were, 
from which the second part, or fructifying portion (fertile 
hyphen), arises perpendicularly ; and third, the free spores, which 
lie thickly strewn upon and in the mycelium. 

1 Archiv fur Ohrenheilkunde, Bd. V., p. 163. 

2 American Journal of the Medical Sciences, Vol. LIX. , 1S70, p. 105. 



ASPERGILLUS, 



147 



The physiological relation of the fruitful fibres to the mycelium is not shown 
in the accompanying cuts, but may be at once made clear by examining a portion 
of common mould with low power. 

The fibres of the pseudo-membrane are unfruitful, branched, straight, or 
curved, and frequently somewhat swollen at the joints. In the broader fibres 
transverse cell-walls are distinguished, and all, broad and narrow, contain faintly 
granular plasma. The breadth of the mycelium fibres was from 0.00015 to 0.0002 
of an inch (0.0038 to 0.005 of a millimetre). 







Fig. 49. 



-Specimen of the Spores and fully developed Growth of the Aspergillus Flaveseens. 
(Caselll.) 



In the fruit-bearing portion are found the changes in form which establish 
the varieties. It consists of a filament, which, especially in the Aspergillus 
nigricans, is stouter than those of the mycelium, bearing upon its summit an 
enlargement, the receptacle or sporangium. 

Those who are interested in a fuller botanical description of the fungus will 
find it in the journal from which I have quoted, as given by Dr. Lewis, in an 
article furnished by Dr. L. and myself, and in Wreden's monograph. 



148 



PENICILLIUM— OTOMYCES PURPITREUS. 




-Penicillium 
Blake). 



(after 



In Dr. Blake's case, which has been alluded to, a portion of 
the specimen was planted upon lemon-peel, placed in a closed 
glass vessel, at a constant temperature of 80° F., when it gave, 
at the end of the third day, a well-developed growth of the Lep- 
tothrix form of Penicillium. 

The specimen represented in the accompanying wood-cut 
exhibited a mycelium and fully devel- 
oped sporangia (a). The spores, of 
which a collection is represented at b, 
were of a brown color and oval outline, 
of about the same size as the spores of 
Aspergillus nigricans. Under a mag- 
nifying power of 300, some of these 
spores showed a double outline. Min- 
gled with this growth there was a close network of very fine 
mycelium. 

Treatment. — The treatment of otitis parasitica is exceed- 
ingly simple, but it is often very tedious, and the practitioner 
must not expect that all the 
aural symptoms will be re- 
lieved when the vegetable fun- 
gus has ceased to appear. We 
may only expect to relieve the 
most troublesome symptoms, 
pain, vertigo, and impairment 
of hearing, by the destruction 
of the parasite. The inflam- 
mation will continue, in some 
cases, long after the micro- 
scope has failed to find any 
traces of aspergillus in the 
auditory canal. 

But the loosened epidermis 
and the flakes of mould should 
be carefully removed every 
day by means of the forceps 
and syringe, the ear being well illuminated while the former is 
used, and the canal frequently douched with warm water by 
means of the fountain syringe or the Fayette douche. I am in 
the habit of pencilling the canal with nitrate of silver in strong 
solutions, after the cleansing process is over, not for the purpose 
of destroying the fungus, but to subdue the inflammation of the 
integument. At the same time, I treat any affection of the 
middle ear, that may co-exist with that of the canal, by the ap- 
propriate means. 




Fig. 51.— Otomyces Purpureus (S. M. Bur- 
nett), a, a, a, a, Younger asci ; &,£>,&, mature 
asci ; c, free spores ; d, mycelium. 



PARASITIC INFLAMMATION. 149 

Dr. Wreden gives a long list of agents which he believes to 
be useful as parasiticides. He mentions, among others, alcohol, 
bichloride of mercury, acetate of lead, tincture of iodine, and 
carbolic acid. He prefers the hypochlorate of lime, which he 
recommends to be used in the strength of one to two grains to 
the ounce of water. The salt must be freshly dissolved in water 
at each application. Fowler's solution ranks next to the lime 
as a parasiticide, according to Wreden. Solutions of tannic 
acid, gr. x. ad. f j., are used by some authorities. 

Drs. Orne Green, of Boston, and Knapp, of this city, concur 
with me in believing that a thorough use of warm water is the 
only parasiticide generally necessary. 

The bichloride of mercury in solution, gr. j. ad. 1 j., and pure 
alcohol are certainly efficient in the destruction of the fungus. 
Either may be dropped into the ear ; alcohol causes some burn- 
ing, but the pain is not usually severe, nor does it last long. 

According to Siebenmann, 1 Kramer described a specimen of 
aspergillus niger with great accuracy in 1859. He does not give 
the reference to Kramer's writings, and I have not been able to 
find it. Kramer found the fungus in the form of a white mem- 
brane upon the membrana tympani. Its inner surface was cov- 
ered by black specks supported by pedicles. The membrane was 
the mycelium, the black points the condiophores. Kramer cured 
his case after many relapses by the use of acetate of lead. 

In the treatment of parasitic otitis it is wise to observe all the 
precautions suggested by Lowenburg : 1. Do not use oils or fats. 
2. Use alcoholic solutions, or solutions containing as little alco- 
hol as possible. 3. Dilute these solutions with boiling water 
before using them. 4. Heat all instruments — that is, wash them 
in boiling water — used in treating aspergillus. 2 

The following cases will furnish a commentary on what has 
been said, and perhaps illustrate the nature cf the affection 
better than anymore extended remarks. The first two have 
already been published, 3 but the third has never before been 
printed. 

CASES OF ASPERGILLUS. 

Case I. — I was consulted, June 30, 1869, by J. F. B , a gentleman Bet, 24. 

in regard to pain and impairment of hearing in the left ear. He stated that 
about a year before he had experienced a sense of fulness in the ear, as if it 
were "stopped up," and that, at the same time, there was considerable tinnitus 
aurium. He consulted a physician, who diagnosticated inspissated cerumen, 



1 Archives of Otology, Vol. XV., p. 180. 

2 Loc. cit. , p. 19G. ' 

3 American Journal of the Medical Sciences, loo. cit. 



150 ASPERGILLUS — CASES. 

and removed a large quantity of what seemed to be ear-wax from the canal. 
The relief afforded was of short duration, for the ear soon filled up. From that 
time to the present the patient has been in the habit of syringing the ear, and 
at times masses of some foreign substance were removed by this process. Of 
late he has noticed black particles strewn in the substance removed, which he 
thinks are due to the entrance of dust from the smoke-pipe of a steamer during 
a recent voyage from Europe. The patient now experiences very considerable 
pain in the ear, and it is the occurrence of this new symptom which has led him 
to consult me. The other symptoms— the sensation of fulness, tinnitus aurium, 
and impaired hearing, continue. Patient's general health is good, though he is 
very subject to naso-phaiyngeal catarrh. 

On examination, a watch which is usually heard at least thirty inches from 
the auricle is only heard one and a half inch, and the auditory canal is filled 
with a lardaceous mass, punctated by minute black spots. This mass was very 
adherent to the walls of the canal, and could not be thoroughly removed by 
syringing, but required the use of the angular forceps, under a good illumination 
by means of Troltsch's otoscope and ordinary daylight. The surface beneath 
this mass, which peeled off from the canal, was red and very sensitive. After 
the removal of the foreign substance, a minute perforation of the membrana 
tympani was found situated in the anterior and inferior quadrant. There was no 
true suppuration, but mucus alone bubbled out from the opening during the in- 
flation of the Eustachian tube. The Eustachian tube was shown to be perme- 
able by Politzer's method, but there was very little sensation experienced in the 
ear when the air was forced in. 

On the removal of the collection, the patient experienced immediate relief 
from the pain and tinnitus aurium, but the hearing was not very much improved. 
The diagnosis catarrh of the middle ear was made, while an exact definition of the 
state of things in the canal was delayed. Portions of the lardaceous, flaky sub- 
stance removed from the canal were placed in glycerine. 

He was ordered to use injections of warm water, by means of Clark's aural 
douche, several times daily, and to drop in a solution of zinc, sulph., gr. ij. ad. 
aqua I j., twice a day. The Eustachian catheter was used, and air injected 
through it into the cavity of the tympanum. 

It was some days before the entire collection was fully removed, and in spots 
where it had been separated and taken out it was renewed very rapidly, and 
each time reproduced the symptoms of pain and fulness. A weak solution of 
carbolic acid wa? then used ; but it caused very great irritation, and inflamma- 
tion was set up, which lasted many days. This was treated by the use of warm 
water, through the douche. When it had subsided, the lardaceous masses were 
removed by the forceps, and in some instances casts of the membrana tympani 
came away, although the walls of the canal showed the most disposition to a re- 
production of the growth. 

July 27th, the opening in the membrana tympani had healed, and the hearing 
so much improved that the watch was heard six inches, and the symptoms com- 
pletely relieved. There was still a slight tendency to the growth of the fungus, 
as it proved to be, on the posterior wall of the canal. The membrana tympani 
was lustreless and rigid, the handle of the malleus distinct, but there was no 
light spot. From the 1st of August I did not again see my patient until October 
18th. Meanwhile he had used the aural douche daily, and the growth had not 
returned : but the catarrhal inflammation of the middle ear had not been materi- 



ASPERGILLUS — CASES. 151 

ally benefited, as shown by the rigidity of the membrana tympani and the im* 
pairment of hearing. The membrane is now (November 19th) somewhat translu- 
cent, and the patient is being treated, with benefit, by means of the injection of 
air, the use of a gargle, etc., for the middle-ear affection. 

The flakes, preserved in glycerine, were examined by my friend Dr. C. E. 
Hackley and myself under the microscope, and Dr. Hackley believed them to 
exhibit specimens of A spergillus nigricans. At a later date Dr. Wm. B. Lewis 
very kindly made a thorough examination, and confirmed Dr. Hackley's opinion. 
In this case it is clearly evident that the growth of the fungus was secondary 
to the inflammation of the middle ear, for the patient never fully recovered his 
hearing power. 

Case II. — September 28, 1869, I was consulted by Mr. S , set. 51, on ac- 
count of impaired hearing, vertigo, pain in the ears, and tinnitus aurium. Ver- 
tigo was the symptom upon which the patient laid the most stress, and of which 
he was most anxious to be relieved. He said that he was so dizzy whenever he 
attempted to walk about, as to be unable to attend to his ordinary business. 
His condition in other respects was excellent. The patient also stated he had 
heard perfectly well until two months since, when he was attacked with the 
aural symptoms narrated above, which had been aggravated since their incep- 
tion. He had been treated by the instillation of oils, and so on. He could hear 
my watch about one inch on the right side, and not at all on the other. Both 
auditory canals were found filled with a tenacious material, which could only 
be removed by the forceps. It was several days before I could completely re-, 
move the firmly adherent coating of the canal and membrana tympani. 

The morbid product was immediately examined by Dr. Lewis, and found to 
be a specimen of the Aspergillus flavescens. Its removal gave the patient great 
relief ; but on the reappearance of the growth, which was in two or three days 
after its thorough removal, the vertigo and tinnitus returned. The membrana 
tympani was intact, but lustreless and rigid. The Eustachian tubes opened 
sluggishly, and there was all the evidence of aural catarrh, besides the affection 
of the canal and of the outer layer of the membrane of the tympanum. The 
free use of warm water, with an astringent, finally subdued the morbid process 
in the canal, so that the patient was able to make a journey to the South. "When 
he left my care, October 18th, the auditory canals were entirely free from ab- 
normal secretion, the hearing was improved, so that the watch was heard from 
five to six inches on the right side, and from one to two on the left. The dizzi- 
ness was entirely gone, and the tinnitus ceased to be annoying. The catarrh of 
the middle ear, as shown by rigidity of the membrana tympani, sluggish action 
of the tubes, and impairment of hearing, still continued. I saw this patient 
about a year afterward, and he was entirely well, his ears having returned to a 
normal condition. 

Case III.— Lt. L . 8Bt. 30, IT. S. N.— December 2, 1S72.— Since a child. 

has been more or less deaf in right ear, owing to a scries o"i abscesses. This 
impairment of hearing was increased by his service near the frequent explosion 
of cannon. About a year ago he had an abscess in left ear (probably in audi- 
tory canal), with considerable purulent discharge having an offensive odor. For 
about two weeks he has had a series of abscesses in the left ear. with consider- 
able discharge of black material. 



152 ASPERGILLUS — SYPHILITIC ULCERS. 

Hearing distance, E. A - , L- &■ 

The tuning-fork was beard more distinctly in the right ear when the handle 
was placed on the forehead or teeth. The pharynx is granular. 

The right membrana tympani is very much sunken and is opaque. 

The auditory canal of that side contains numerous scales of epidermis strewn 
with black spots. 

The left canal is full of pus, and the membrana tympani is perforated. 

The microscopic examination showed the presence of the aspergillus nigri- 
cans in both auditory canals. 

The patient's general condition was excellent, except, as is the case with 
most aural patients, he was somewhat despondent on account of the loss of 
hearing. 

The diagnosis of chronic suppurative inflammation of the middle ear, with 
aspergillus growth, was made as regards the left ear. In the right, there was 
chronic non-suppurative inflammation with the same fungus growth in the audi- 
tory canal. 

The patient was seen nearly every day until December 24th, and treated by 
the use of leeches, the syringe and warm water, with the subsequent applica- 
tion of nitrate of silver, gr. xl. ad. § j., brushed over the canal and drum-head. 
The patient also caused his ears to be syringed at home, and instilled a solution 
of sulphate of zinc, two grains to the ounce, into the ears. The Eustachian 
catheter and Politzer's method were used to force air into the middle ears, and 
the patient used a gargle of chlorate of potash. 

The aspergillus fungus disappeared in a few days, but the affection of the 
middle ear and canal lasted much longer. 

On the 24th of December, however, just twenty -two days after he came un- 
der treatment, Lt. L was discharged, with hearing distance for watch, 

Oi -i q 

R.-.-^, L-—. At sixteen feet distant he could hear and carry on a conversa- 

4:0 4o 

tion in the ordinary tone, with his face away from the speaker. The left canal 
still continued to swell, and the epidermis to scale off. The patient had eczema 
of the scalp and auricle. Some weeks after he was said to be still improving. 

Cases of the formation of vegetable fungi in inflamed audi- 
tory canals are now matters of such every-day occurrence, 
among those that see much of aural disease, that they are not 
cases of great interest. Nevertheless they are of considerable 
importance. Their origin should be understood and their occur- 
rence not overlooked. 



SYPHILITIC ULCERS— CONDYLOMATA. 

In the course of secondary syphilis ulcers and condylomata 
may occur in the auditory canal, just as syphilitic eruptions may 
occur on the auricle and on other parts of the general integu- 
ment. They are, however, somewhat rare. The manifestations 
of syphilis in other parts of the body, with the characteristic ap- 
pearance, and the absence of itching sensations, will usually 



NARROWING OF CANAL — DIPHTHERITIC INFLAMMATION. 153 

make the diagnosis quite clear. While it is true, as Schwartze 
intimates, 1 that it is sometimes difficult to decide whether a given 
case of granulations in the auditory canal depends upon a syphi- 
litic dyscrasia or not, since the anatomical constitution of the 
tumors are the same whether syphilitic or not, yet this is not 
usually the case. There is no more difficulty in making a diag- 
nosis here, than in determining whether a case of iritis is or is 
not caused by the poison of syphilis. Of course it is important to 
decide as to the existence of syphilis in a person suffering from 
ulcers or granulations of the auditory canal, for if syphilis be 
not present, local treatment will often be all that is required.. If, 
however, the ulcers be the manifestations of the venereal poison, 
or be modified by it, the use of mercury and iodide of potassium 
will be essential. 



NARROWING AND CLOSURE OF THE CANAL. 

Of congenital closure of the auditory canal in connection 
with absence or deformity of the auricle, I have already spoken. 
There remains to be mentioned, however, a narrowing, or even 
closure of this passage, which sometimes occurs as a result of a 
neglected inflammation — usually if not always of an ulcerative 
character. It will perhaps be better to discuss the whole subject 
of contractions of the canal under the head of bony growths, 
exostosis and hyperostosis, these being usually the result of in- 
flammatory action. I will therefore refer the reader to the 
chapter upon the results of chronic suppuration for a considera- 
tion of the subject of closure of the canal as a result of inflam- 
mation. 

DIPHTHERITIC INFLAMMATION. 

That diphtheria of the middle ear may and does occur, has 
been shown by numerous observers. I have seen it in one case 
where no antecedent inflammation of the middle ear existed. A 
suppurative inflammation of this part may readily take on a 
diphtheritic form in case the patient be attacked with the consti- 
tutional disease. I have never seen diphtheria oi' the canal, but. 
as we should imagine, it is sometimes developed on the excori- 
ated parts of an auditory canal already suffering from simple 
inflammation during an epidemic of diphtheria. 



1 Arcliiv f iir Ohrenheilkuude, B. IV., p. 003. 



154 SARCOMA — CARIES. 



SARCOMA OF THE CANAL. 

I have seen one case of tumor in the canal, which was said 
by a competent microscopist, Dr. Welch, to be a round-celled 
sarcoma. The case is elsewhere reported in full by Dr. Buck, 1 
who sent it to me for consultation. The patient was a girl of 
fourteen. The first intimation that she had of trouble was a ful- 
ness and pain in the part. The canal was found to be filled up 
near the meatus by a firm fleshy mass. It sprung by a broad 
base from the upper and posterior wall of the bony part of the 
canal. The child was healthy in all other respects. Besides the 
marks of sarcoma Dr. Welch found osseous tissue in the centre 
'•with wide medullary spaces in which the tissue is rich in cells 
and fibrillated." Dr. Welch pronounced the tumor to be osteo- 
sarcoma, taking its origin most probably from the periosteum. 
Dr. Delafield confirmed Dr. Welch's opinion, and he added if the 
bone be not involved and the tumor can be completely removed, 
the prognosis is not very bad. Dr. Buck, Dr. Weir, and myself 
agreed that the tumor should be completely removed, which was 
done by Dr. Buck, under ether, by means of knives and a sharp- 
edged steel scoop. A zone of skin, apparently healthy, surround- 
ing the entire base was also removed. The growth sprung from 
the periosteum. The exposed bone was scraped and a solution 
of chloride of zinc, forty grains to the ounce of water was 
painted over the exposed surface. The patient, who was of 
strong and healthy parents, did perfectly well, and remains well 
four years after the operation. Dr. Buck, in closing his account 
of this remarkable case, states that the maternal grandmother 
died of some uterine disease which may have been cancerous in 
its nature, and that a grand-aunt and two second cousins suf- 
fered from cancer. 



CARIES OF THE AUDITORY CANAL. 

Death of the bony wall of the auditory canal with no disease 
of the tympanic cavity, is not a common affection, but it may oc- 
cur. I have under my care, while writing this, a gentleman of 
more than eighty years of age, who, while not suffering from 
any other form of aural disease, has an affection of this kind. 
Just at the junction of the osseous with the cartilaginous canal, 
anteriorly, the bone is diseased, and my associate, Dr. Emerson, 
has removed a small piece of dead bone from it. The disease be- 

1 Diseases of the Ear, p. 121. 



CARIES OF CANAL. 155 

gan as a severe local inflammation of the canal furuncle, for 
which the patient was treated by his physician in Newport, Dr. 
Rankin. The symptoms, which were severe, abated, and when 
Dr. Rankin referred him to me, at the end of the summer, there 
was some tenderness at the junction of the auricle with the 
bone, and an offensive discharge of pus, but no serious general 
symptoms or disease of other parts of the ear. In a few days 
loose bone was detected and removed. The bone does not heal. 
It is some four months since the occurrence of the original in- 
flammation, but the surrounding parts are now free from ten- 
derness and pain. The indications of treatment are, of course, 
to keep the opening free from granulations and pus, and to favor 
the throwing off of the bone. At the advanced age of my pa- 
tient, I feel obliged to content myself with mild measures. I 
occasionally scrape the granulations and also the surface of the 
bone with a curette. 

I have seen one case of nearly complete absence of the audi- 
tory canal, to which I am puzzled to assign a place, or rather I 
am uncertain whether it belongs among the cases of bony 
growth from inflammation in infancy or in intra-uterine life, or 
with those of arrested development. It may perhaps be properly 
inserted at the close of this chapter. 

Dr. "W. J. Welch, sent to me for advice, a very interesting case of closure of 
the auditory canal. The patient was twenty years of age, said to be " deaf 
since he was five years of age." His ears were never treated, and he had not 
grown worse. He has always been well in other respects. He is intelligent. 
His ancestors were healthy people. He never had a discharge from his ears, and 
very rarely has he had an earache. His hearing distance is : right ear, ™^ c - ; 
left, the same. The voice is heard behind him three feet. The bone conduc- 
tion seems to him louder than aerial. The duration is about the same as aerial. 
The auditory canals are each less than half an inch deep, and funnel-shaped. Air 
enters the tympanic cavity by Politzer's method of inflation. No change in the 
hearing distance is observed after inflation. 

I considered the condition as congenital, and no treatment 
was urged upon the patient, although an explorative opening of 
the canal by a dentist's drill was suggested. Whether this bony 
closure of the canal was the result of intra-uterine inflammation 
or merely of arrested development of the canal, remains an un- 
solved problem to me. If the former be true, then the ease is 
one of hyperostosis of the canal. It is possible that an inflam- 
mation occurred in early infancy, which led to closure of the 
canal. In the chapter upon the " Consequences of Chronic 
Suppuration, 1 ' this subject Avill again be discussed. 



CHAPTEK VII. 

INSPISSATED CEBUMEN. 

Merely a Symptom of Aural Inflammation. — Frequency of the Affection. — Symp- 
toms. — Reported Cases of Damage to the Ear from the Presence of Wax, probahly 
not based on Correct Observation. — Causes. — Treatment. — Cases. 

Although I am convinced that the hardening of cerumen is 
merely one of the symptoms of aural inflammation, I do not 
feel as yet justified in discussing its nature and treatment in 
an incidental manner. As a symptom, inspissated cerumen is so 
prominent or annoying, that it has been classified as a separate 
disease for a long time, if not always, although it is merely, in 
my opinion, a consequence of an inflammation. 

The writers on otology of the future, will, I am sure, treat of 
hardened cerumen in connection with their accounts of the dis- 
eases of the external and middle ear, and will not award it a 
place by itself, although the writers of the present day do not as 
yet feel justified in this manner of discussing it. 

Among the laity, and even in the profession, hardening of 
the ear-wax is generally regarded as a very harmless affection. 
It is also considered by many as the most common of all the 
diseases of the ear. The first treatment that many aural pa- 
tients receive at the hands of their medical advisers, is a vigor- 
ous syringing, or worse still, probing, in order to see if the wax 
be not hardened. 

Now the facts are, that inspissation of cerumen is, compara- 
tively, not one of the common affections of the ear, and that 
when it does actually occur, it is by no means the simple and 
harmless disease that it is often supposed to be. Of 4800 aural 
cases observed by myself in private practice, only 339 were what 
might fairly be said to be cases of inspissated cerumen ; that is 
to say, cases in which the impaction of ear-wax was the chief 
of the aural symptoms. 

In the Manhattan Eye and Ear Hospital, of the 10,100 aural 
cases recorded in thirteen years, 1084 are classified as cases of 
inspissated cerumen. Yet, in a large proportion of these, it is 



INSPISSATED CERUMEN. 157 

admitted by the attending surgeons, that the hardened wax was 
but a symptom of what may have been more serious disease. I 
have found that it is the habit in certain circles, to speak of 
the hardening of cerumen, as if it were a trivial affection which 
almost any one is competent to manage, and one that needed no 
considerable attention. 

In the first place, no one is competent to remove hardened 
cerumen without careful instruction, and in the second, it is a 
significant symptom, the careful study of which will in many 
cases be of great value in preserving the hearing of the person 
affected with it. Hardening of the cerumen often occurs in the 
course of suppurative processes in the middle ear, as well as in 
cases of chronic non-suppurative disease. It also occurs in dis- 
ease of the internal ear — the nerve or labyrinth. In such cases 
removal of the wax may slightly or even considerably improve 
the hearing. If it be improved, a superficial examiner may be led 
to believe that impaction of the wax was the only disease, but an 
exact test of the hearing power will often convince him that the 
patient still has defective hearing, even though it be greatly 
benefited by the removal of a large plug of cerumen. The cases 
of inspissated cerumen, in which the hearing becomes perfect 
after its removal were in the beginning, I believe, cases of in- 
flammation of the canal or of the tympanic cavity, which have 
run their course, leaving behind them the wax made hard by the 
evaporation produced by the abnormal heat, when the canal or 
tympanum or both were inflamed. 

Cases are sometimes presented to me, where the patient can 
state positively that there was, some time anterior to the impair- 
ment of hearing from the blocking up of the ear, a period, 
although a brief one, of decided pain. In many cases also, it is 
easy to see the evidences of inflammation in the epidermis of the 
canal, after the wax has been removed. In some, I grant that 
it is not, but I feel confident that close examination will show in 
every case, a probability at least, that an inflammation in some 
part of the ear, a morbid condition, preceded the period when 
the wax was not removed by the motions of the jaw, but when 
it remained as a nucleus about which the whole secretion of 
the canal collected, until it finally became an obstruction to 
hearing. In my opinion, the proper way to classify inspissated 
cerumen would be to say, for example, inflammation of the canal 
with inspissated cerumen. Suppurative inflammation of the 
middle ear with inspissated cerumen, and so forth, 1 speak thus 
in detail, upon this point that inspissated cerumen is but a symp- 
tom, because I believe that many curable cases are dismissed 
with but partial relief, because it is thought when its removal is 



158 INSPISSATED CEKUMEN — SYMPTOMS. 

secured and the hearing is much improved, that impaction of the 
wax is the only disease. In many of these cases, unless the ear 
be subjected to appropriate treatment, not only may the wax 
soon become again inspissated, but the fundamental disease 
which caused the impaction of the wax remains uncured, and it 
may become permanent. From careful observation, I believe I 
may state, that the activity of the ceruminous glands is usually 
increased, and the canal becomes exceedingly hot and moist 
during a subacute or acute catarrh of the tympanic cavity. It 
is in this increased action of the glands that the beginning of 
impacted cerumen is to be sought. 

Symptoms. — The prominent symptoms of true cases of inspis- 
sated cerumen are : 1. Sudden impairment of hearing. 2. Tin- 
nitus aurium. 3. Vertigo. 4. Pain in the ear. 

The practitioner will not need to spend much time in deter- 
mining the cause of such symptoms. If they be produced by 
impaction of the cerumen, a glance at the auditory canal by 
means of the speculum and otoscope will determine the matter, 
or at least it will give us positive evidence as to the presence of 
the inspissated substance. It need hardly be said, that the prac- 
tice of probing the ear to determine if the wax be hardened, is 
an extremely unphilosophical procedure, while it is not without 
danger to the membrana tympani. I am obliged to say, how- 
ever, that I have seen several cases in which this probing has 
been undertaken without ocular examination ; and where in- 
flammation of the lining of the canal, of the drum-head, and in 
one case even perforation of the membrane, had resulted from 
the manipulations in the dark. 

The appearance of inspissated cerumen is very character- 
istic. Wax which presses upon the walls of the canal and upon 
the membrana tympani, in adults, is of a dark brown or black 
color, and usually fills the canal. In children, however, in 
whom the disease also occurs, the wax is usually of a yellow 
color, and is more apt to be in layers. The presence of even 
quite an amount of soft yellow cerumen, which still leaves an 
opening, however narrow, down to the drum-head, can hardly 
cause any unpleasant symptoms. 

The diagnosis of inspissated cerumen is sometimes obscured, 
by the useless habit indulged in by so many of the laity and of 
the profession also, of pouring olive or other oils into the audi- 
tory canal on the appearance of any aural symptoms. A lady 
once came from St. Louis to consult a New York physician in 
regard to a loss of hearing. She had been seen by no less than 
six medical men, all of whom had prescribed applications to be 
dropped into the ear, and none of whom had made an examina- 



INSPISSATED CERUMEN— SYMPTOMS. 159 

tion. She had suffered for six years from the great impairment 
of hearing, and came to New York as a last resort. Having 
arrived here, she was sent to me. I found the ears filled with 
oils, but beneath all this, hardened cerumen, which was easily 
removed ; and, although her hearing had been impaired for so 
long a time, the removal of the wax restored it to the normal 
power, so that she heard ordinary conversation with ease, and a 
watch several feet. In this case, I did not imagine, until the 
ears were cleansed by the syringe, that impacted cerumen was 
the cause of the loss of hearing. I could scarcely believe, that 
oils would be persistently dropped in an ear by so many different 
advisers, before the membrana tympani had been examined. 

The tuning-fork will be of use, if the inspissated cerumen be 
confined to one side in determining the prognosis ; but practi- 
cally the better plan is to defer any statement as to the prog- 
nosis until the cerumen is removed. 

In cases of disease of the acoustic nerve with impacted wax, 
the tuning-fork will sometimes be heard better by bone than by 
aerial conduction, but when the wax is removed, the hearing re- 
mains impaired, but the tuning-fork is heard better through the 
air than through the bones. Of course, if the hearing be nearly 
or absolutely gone from disease of the nerve, the presence of 
wax will make no difference in the ability to hear the tuning- 
fork, so that, if the tuning-fork be not heard better through the 
bones with impacted wax, the prognosis as to improvement of 
the hearing is very poor. 

The loss of hearing from hardening of the cerumen, as has 
been intimated, is apt to occur very suddenly. I have seen sev- 
eral cases where patients could tell the very instant when the 
ear "closed up," as they often say. The jolting of a ride in a 
New York stage often displaces the hardened material, and 
presses it into the canal, causing troublesome symptoms in an 
instant ; and, as I have said, these symptoms do not occur, no 
matter how much cerumen may be in the ear, until the impac- 
tion takes place, when the loss of hearing, the tinnitus aurium. 
and the increased resonance of the patient's own voice, calls his 
attention to the ear. 

Pain of the most distressing nature sometimes occurs from 
the impaction of cerumen. I remember one case where ano- 
dynes had been used for ten days to relieve a pain in the ear. 
which an examination showed was the result of the affection 
now under consideration. In another case, that of a young 
lady, suppuration of the drum-head resulted from the long-con- 
tinued impaction of cerumen. This suppuration was preceded 
by very severe pain, from which no relief was experienced until 



160 MENTAL DEPRESSION FROM HARDENED WAX. 

the mass of cerumen was evacuated spontaneously, like a cork 
from a bottle of champagne, and, as the patient stated, with a 
report like that of a pistol. The removal of a plug of cerumen 
from the auditory canal of the other side, a plug that was very 
tightly wedged in, saved the patient from a similar experience 
on that side. 

These rare cases of suppuration caused by wax, should not 
be confounded with those frequent ones of chronic suppuration 
where the wax hardens over the opening of the membrana 
tympani. 

It is probable that some of the cases reported by the earlier 
authors as instances of great damage to the ear from inspis- 
sated cerumen, were cases of this kind. Toynbee's * cases of 
absorption of the bone, imbedding of wax in the mastoid cells, 
are possibly only cases where hardened wax supervened upon 
chronic suppuration of the middle ear. 

Among the cases that are appended to this chapter, will be 
found another where excruciating pain was one of the promi- 
nent symptoms of a case of inspissated cerumen. Yet neither 
pain nor vertigo are the ordinary symptoms of this disease ; im- 
pairment of hearing and tinnitus are the usual ones. 

Great depression of spirits, almost becoming melancholia, 
was observed in a case reported by Dr. Edward T. Ely and 
myself. 2 

MENTAL DEPRESSION FROM IMPACTED WAX. 

Mr. T , set. 18, has been seen at intervals for several years on account of 

a chronic suppuration in the right middle ear. The left ear was normal. On 
May 15, 1879, the right ear was in very good condition ; the hearing was £§, and 
there was no discharge. Patient came again on September 24th, complaining 
that since June he had suffered from "a feeling of heaviness in his head." 
Was "unable to concentrate his mind on anything for more than a few min- 
utes." Felt as if he must give up his studies (in which he was very much inter- 
ested), and wished to know whether he must leave college. Thought his deaf- 
ness had increased, but had no pain, tinnitus or discharge. The patient was 
sullen and very despondent. Otherwise his health seemed to be excellent. He 
was very reticent by nature. 

H. D., E,. -£q. External auditory canal filled with hard wax. After remov- 
ing the wax, the hearing became \% and the tympanic cavity looked as it had at 
former visits ; there was no discharge. 

The patient obtained speedy relief, and in a few days reported the discom- 
fort about his head gone. He was then as cheerful as usual. 

This case was interesting, as illustrating the disturbing influence of impacted 
wax, even with an entire absence of tinnitus. 



1 Text-book, English edition, p. 51. 

2 Archives of Otology, Vol. IX., p. 16. 



INSPISSATED CERUMEN — CAUSES. 161 



CAUSES. 

The causes of hardening of the wax in the auditory canal are 
not as well settled as we could wish. As I have already observed, 
I no longer believe that it is an independent affection, or a dis- 
ease only of the ceruminous glands. There are cases, however, 
in which at the time of the removal of the inspissated cerumen, 
its presence is the only bar to a perfect recovery of the hearing 
power. In such cases the disease which caused the wax to 
harden has passed away, and it only remains as a foreign body. 
Yet in by far the majority of cases the hearing is not fully re- 
stored by the removal of the wax. I will tabulate the diseases 
in which hardening of the wax may occur. 

I. — Chronic Suppuration of the Middle Ear. 

Hardening of cerumen in such cases is not always injurious. 
A layer of hard wax sometimes serves as a good artificial drum- 
head, and improves the hearing. When the mass has become 
thick enough to cause pressure, pain, tinnitus and vertigo may 
result, and it should be removed. It is important, therefore, in 
extremely chronic cases of suppuration of the middle ear, to 
remember that a layer of black wax may be sometimes more 
profitably left than removed, since it sometimes acts as an arti- 
ficial membrana tympani. It is to be understood, however, that 
this is not the rule when there is a hope of healing the mem- 
brana tympani by local treatment. 

II. — Chronic Non- Suppurative Inflammation of the Middle Ear. 

The symptoms of patients suffering from this form of disease 
are often aggravated by impaction of the cerumen. So unob- 
servant are many as to a loss of hearing, that until a plug of 
wax has closed the canal and rendered hearing of ordinary 
conversation carried on near them, very difficult, do they admit 
that their hearing is at all defective. In such cases the rule is 
without exception to remove all the hardened material. 



III. — Diffuse Inflammation of the Auditory Canal. 

I have seen hardening of the wax, especially in children, in 
the course of this disease. As has been before intimated, the 
black color that usually indicates hard wax in adults is not 
found, when it is impacted in the ears of children. The mixture 
of layers of epidermis with the wax is more marked in these eases 
than in others. 
11 



162 INSPISSATED CERUMEN — CAUSES. 

IV. — Foreign Bodies. 

The cerumen may become impacted in the ear in cases where 
foreign bodies have been placed in, or have entered the auditory 
canal, and have not been removed. I have on several occasions 
removed hardened wax that contained insects that had entered 
the ear. In one case, that of a little boy, the parents remembered, 
on questioning, that he had once, about a year before, complained 
of pain in his ear for a few hours, and that he had said some- 
thing was in his ear. The pain was stilled and the occurrence 
was forgotten until new symptoms appeared, such as impairment 
of hearing and tinnitus. An examination revealed impacted 
cerumen, in the centre of which was found an insect. 

Y. — Exostosis and Hyperostosis of the Canal. 

Impacted cerumen occurring in a case where the canal is 
narrowed by a bony growth, is difficult to manage, for it is 
particularly difficult to remove the wax when it lies behind the 
contraction of the osseous canal. I have one such case in my 
mind as I write, that of a physician from the South, who in his 
annual visits to the North, is obliged to devote as much time to 
getting the hardened wax from his auditory canal, as is usually 
devoted to the care of the teeth. The presence of the wax great- 
ly diminishes his already impaired hearing. Even a thin layer 
lying on a part of the drum-head is sufficient for this. In his 
case, the connection of the hardening and massing of the ceru- 
men, with an inflammatory condition of the canal is very plain. 

VI. — Parasitic Inflammation. 

Impaction of cerumen is not at all unlikely to occur in con- 
junction with parasitic inflammation of the canal. As was inci- 
dentally mentioned in the preceding chapter, wax may harden 
upon a growth of aspergillus in the canal and upon the drum- 
head. 

While these pages are passing through the press I have un- 
der my care a boy of eight years of age, who came to me some 
four weeks ago on account of defective hearing. Both his audi- 
tory canals were found to be filled with impacted cerumen, which, 
as is apt to be the case in children, was removed slowly and 
with difficulty. Dr. Emerson, my associate, has spent many 
hours upon the case, using the syringe, curette, probe, and for- 
ceps at each sitting. When several layers of wax had been re- 
moved, we found aspergillus of luxuriant growth underneath, 
clinging closely to the canal and membrana tympani. 



INSPISSATED CERUMEN — CAUSES. 103 

Sometimes the patients with inspissated cerumen say that 
they perspire excessively ; and again, they are not at all aware 
of any such peculiarity. Often, indeed, they state positively that 
they do not perspire any more than is natural. I think, there- 
fore, we must reject this from among the causes of this disease, 
although it is given by some authors. 

I have no doubt that the bad habit of cleansing the audi- 
tory canal with the end of a towel, or with an aurilave — a bit of 
sponge fastened on a handle — or the like, has a tendency to pack 
the cerumen in the canal ; but after all, a cause must, I think, 
be sought for behind this, and this is to be found in an inflam- 
mation of the middle ear, which has extended to the auditory 
canal, or in an inflammation of the canal itself. 

I have observed that almost all patients suffering from inspis- 
sated cerumen ascribe the attack to "cold" which they have 
taken. In many of these cases no evidence is found to sub- 
stantiate the theory, for, as all my readers know, patients are 
very apt to ascribe all kinds of diseases to cold, even when they 
cannot positively remember that they have suffered from a cold 
in the head, throat, or chest. Yet many cases have come to me, 
in which there was a naso-pharyngeal catarrh coincident with 
the impaction of cerumen, or with the aural symptoms. 

I suppose a very slight swelling of the auditory canal would 
prevent the free removal of the cerumen, which naturally takes 
place from the motion of the lower jaw, as it presses upon the 
lower part of the wall of the meatus. When the wax has once 
collected, partial evaporation of its watery contents occurs, and 
we get the characteristic black color, and the mass becomes, on 
its surface at least, as hard as soft wood, and in rare cases as 
hard as some kinds of stone. 

Cases enough have been seen to show, that inflammation of 
the canal does favor inspissation of the cerumen ; the only ques- 
tion upon which any doubt may be thrown is, whether impaction 
of cerumen does ever occur without an antecedent inflammation, 
and "Prom purely mechanical causes, such as packing- of the secre- 
tion by improper attempts to cleanse the canal, or from a peculiar 
tendency to excessive, action of these numerous glands. Certain 
it is, that some cases require only local treatment, and that what- 
ever inflammation preceded the evaporation of the fluid of the 
cerumen, was fully removed when the patients came under treat- 
ment. 

Many patients suffering from chronic non-suppurative inflam- 
mation, complain that their ears secrete no wax. This state of 
things is due to two facts : One is. that such patients are very 
apt to syringe their ears very frequently, and thus remove ail 



164 GLYCERINE AS A REMEDY FOR DEAFNESS. 

the cerumen as fast as it forms. The other is, that the chronic 
catarrhal, or proliferating process, probably extends to the audi- 
tory canal, and interferes with the functions of the ceruminous 
glands. 

Under the guidance of Mr. T. Wakely, who published an 
account of the wonderful virtues of glycerine in the London 
Lancet,' the profession were at one time very much in the habit 
of recommending the use of this agent to re-establish the secre- 
tion of cerumen. Mr. Wakely even published a work entitled 
'•'Clinical Reports on the Use of Glycerine in the Treatment of 
Certain Forms of Deafness." Mr. Wilde showed that the reporter 
of these cases was not ''conversant with either the normal or 
pathological appearances of the ear," and glycerine, after a fair 
trial, which is still kept up by some physicians, proved to be of 
no avail in relieving impairment of hearing. Its only value is 
as an emollient to soothe an irritated or dry canal. It should be 
diluted with water when used in this way. 

Its use for the restoration of the secretion of cerumen was 
about as rational as the other instillations, of which an account 
has been given in the introductory chapter. Yet in our own 
century, a surgeon to a London hospital gravely recommended, 
as a portion of a new cure for deafness, "the finest curled wool 
on the sheep's head, carefully cut with scissors, and washed in 
hot water," and added "that the best wool is that procured from 
a small German sheep ;" 2 while in the same city, Wakely's book 
was gravely noticed as a contribution to clinical medicine. 

From present appearances another quarter of a century will 
pass away, before many physicians will cease to advise the use 
of glycerine and sweet oil, for a disease of the ear, of the exact 
nature of which they know nothing. Were it not that valuable 
time is often lost in the treatment of inflammation of the ear, 
in many cases where this advice is given, there would not be 
much to regret, since in many instances the glycerine or oil 
softens the hardened wax, so that its position is changed at 
least. Sometimes it even effects a removal of it without the 
use of a syringe, but for one case where inspissated cerumen 
actually exists, when this advice is given without an examina- 
tion, there are a score where there is no hard wax to soften, 
and where the advice is positively harmful. Glycerine, as usu- 
ally prescribed for the ear, has very few antiphlogistic virtues. 
It usually perpetuates rather than cures an inflammatory process. 

Treatment. — The treatment of inspissated cerumen is exceed- 
ingly simple. The hardened material should be removed by the 

1 Wilde's Aural Surgery, p. 38. 2 Wilde, loc. cit. , p. 43. 



INSPISSATED CERUMEN — TREATMENT. 165 

use of the syringe and warm water. The syringing should be 
performed in the manner that has been depicted on page 133. 
In the majority of cases but a few minutes are necessary to re- 
move the mass. In some cases, however, we are compelled to 
use a solvent for a few hours prior to the syringing process. I 
usually use a saturated solution of the bicarbonate of soda for 
this purpose. The cerumen is sometimes so hard, and so tightly 
wedged into the auditory canal, that a daily sitting for a week 
or more is necessary to its removal. I have notes of several 
such cases. In one of them, I finally softened the mass by the 
use of fuming nitric acid, after having completely failed to 
make any impression upon it by alkaline solutions or oils. 

Professor S. D. Gross recommends a pick and curette for the 
removal of inspissated cerumen. He says : " Ear-wax, however 
hard, or however firmly impacted, is more readily removed with 
such an instrument than with any other contrivance of which I 
have any knowledge." 2 I am constrained to say, that I consider 
such advice from so eminent a source as the distinguished Pro- 
fessor in the Jefferson Medical College, calculated to give a 
dangerous and false impression as to the proper method of re- 
moving ear-wax. The syringe and warm water will be found 
to be the only means that are necessary in ninety cases out of a 
hundred. The use of the "pick and curette," or of any pointed 
instrument, is a dangerous means of removing inspissated ceru- 
men, except in the hands of men of very large surgical experi- 
ence, who have learned to treat ears as if they were soap-bubbles. 
It is only in the rare cases in which the syringe fails that the 
use of an instrument, employed under a good illumination by 
means of the mirror and forehead band, should be resorted to. 

In some cases it will be necessary to lift the first layer of 
hard wax with a delicate probe before the syringe will make any 
impression upon it. In others, this will be necessary even down 
to the last layer. In such cases the curettes of Buck and Politzer, 
used under good illumination are of great assistance. Too great 
stress, however, cannot be laid upon the necessity for care in the 
use of instruments upon the auditory canal, especially near the 
drum-head. In the hands of the average practitioner, the syringe 
is the best instrument for the removal of impacted cerumen. 
because it is usually efficient and always safe. Dr. Pomeroy- 
recommends a syringe "with a flange and a long narrow tip " for 
the removal of hardened wax. The stream of water from the in- 
strument is no doubt efficient, but I think this syringe in unprac- 

1 American Journal of the Medical Sciences, October, 1864a 

2 Text-book, p. 85. 



166 INSPISSATED CERUMEN — TREATMENT. 

tised hands is more dangerous than a probe, and I still use a 
short nozzle as seen on page 132. When it becomes necessary to 
make an opening in wax upon which the stream of water may 
act, nitric acid may be used, or a saturated solution of caustic pot- 
ash (Blake), a small hole being burned in the centre of the mass. 

The auditory canal may contain a surprisingly large quantity 
of hardened cerumen, and it is necessary to examine the ear 
quite often during the syringing process, in order to see how 
much remains, lest we continue the injections after the wax is 
removed, and thus injure the drum-head. All the wax should 
be removed. The thinnest scale or flake left upon the drum- 
head, is sometimes sufficient to keep up the disturbing symptoms. 
I have seen several cases where the diagnosis was correctly 
made, and the syringing undertaken, and yet the symptoms 
were not relieved, because a small flake of wax was left upon 
the drum-head. 

The membrana tympani is usually found very much reddened 
after the removal of the wax ; but this is probably due to the in- 
jections of warm water. It is also sometimes pressed inward. 
This may be due to the mechanical pressure which has been ex- 
erted upon it by the cerumen, or to the catarrh of the tympanic 
cavity which so often accompanies or causes this disease. 

If the hearing is very much improved after the removal of 
the wax, the ear should be protected from the shock of sounds 
by a little pledget of cotton placed lightly in the meatus. If the 
drum-head be sunken inward, Politzer's method of inflating the 
middle ear, or the Eustachian catheter, should be employed to 
restore it to a normal position. Since some persons are disposed 
to frequent attacks of inspissated cerumen, it is well to advise 
them to have the ear syringed with warm water once in two or 
three months. It is probable that it requires a longer time than 
this, for cerumen to become so hard or so tightly packed in the 
canal, that it cannot be readily removed by the patient or a non- 
medical friend. 

It is always well to examine both ears, even when only one is 
complained of. I have often found the ear in which the hearing 
was still unimpaired, quite as full of wax as the other, although 
it had not yet become pressed upon the drum-head, and thus had 
given no trouble. 

I append a few cases, which illustrate what has been said, 
and which will, perhaps, contribute to a knowledge of the eti- 
ology of the disease. 

Case I. — Buzzing Noise for Two Days, then Pain — Insjnssated Cerumen. — 

March 5, 1873, Mr. De S , set. 28, consulted me about a pain in his ear. 

Two days since he experienced a "buzzing noise" in the ear, and last night he 



INSPISSATED CERUMEN — CASES. 167 

had severe pain in it, which was relieved by some liquid application. The buzz- 
ing noise still continues, and he cannot hear well from the left side. 

The hearing distance is : Eight ear, normal ; Left ear, j P 8 , or the watch is 
heard when pressed upon the auricle. 

Tuning-fork is heard much better on the left side. 

Diagnosis : Inspissated cerumen in left ear. 

The mass was removed by syringing, and the hearing distance became |f in 
a few moments. 

Case II. — Head Symptoms for some Months, ascribed to Sunstroke — Treated 
for Cerebral Disease, without Examination of the Ears — Inspissated Cerumen — Re- 
moval — Cure. — A. B , coachman, at New York Eye and Ear Infirmary, in 

1864. The patient complained of head symptoms for some months. He ascribes 
them to a sunstroke. On cross-examination it was found that he had never act- 
ually suffered from sunstroke ; but that since his head symptoms — chiefly 
buzzing in the ear and deafness — had begun, he imagined that they were caused 
by a fancied sunstroke. 

He stated that he had been treated in a New York hospital for some weeks, 
but without benefit. His ears had never been examined, and he had concluded 
to have their condition investigated, as many of the symptoms which made him 
' ' bad in the head " were referred to his ears. 

An examination showed inspissated cerumen in both ears. I have mislaid 
the record which gave an account of his hearing power ; but all the trouble- 
some symptoms were at once relieved by the removal of the mass, which was 
done by the use of the syringe. 

This case is almost as striking as that related by Troltsch, 
in which a poor fellow was blistered and cupped to the verge of 
severe depression for a supposed concussion of the brain, which 
proved to be caused by inspissated cerumen. 

Case III. — Abscesses near the External Meatus — Impaction of Cerumen — Res- 
toration of Hearing after Removal of the Cerumen. — The following case shows, I 
think, that a swelling of the canal may prevent the normal exit of the cerumen, 
and thus favor its impaction : 

Miss J , set. 29, consulted me March 23, 1873, on account of her ears, 

and gave the following history : For fourteen or fifteen years she had suffered 
at intervals from abscesses in both ears. The hearing has been seriously im- 
paired on the right side from an ulcer resulting from scarlet fever, since she 
was five years old. For the past two or three months the hearing has been 
impaired in the left ear, and she has suffered from abscesses near the external 
meatus, which have caused great swelling and tenderness of the parts. The 
impairment of hearing was most marked in the morning. For the last four 
weeks she has been constantly deaf, although for a few momenta a few days ago 
she heard very well ; she then felt as if something had broken in the ear. 

Hearing distance, tested by the watch : Eight ear, - 4 °s ; Left ear. 

Diagnosis. — Right ear, chronic suppuration in tympanic cavity. Left ear. 
inspissated cerumen. A small furuncle was found in the outer part of the 
canal, which was a very narrow one. 



168 CASE OF RECU.REENT INSPISSATION OF CERUMEN. 

The mass of cerumen was removed in about twenty minutes by syringing, 
when the hearing distance became -&. 

Politzer's method of inflating the ear was then employed. 

March 6th: H. D., &. 

After the use of Politzer's method, the hearing distance became f §. 

The above case illustrates the theory of the preceding chap- 
ter, that inspissated cerumen is in reality but one of the symp- 
toms of certain forms of inflammatory affection. In this case 
the inflammation had not fully run its course, for the canal was 
red and swelled. Perhaps, indeed, this was an habitual condi- 
tion of the part. 

Case IV. — Recurrent Attacks of Inspissated Cerumen for Twenty Years — Ul- 
ceration of Membrana Tympani during Two Attacks — Recovery, but Inspissation 
of Cerumen continues to recur. — I have under observation and care a gentleman 
of about thirty-eight years of age, who has suffered from attacks of inspissation 
of cerumen for more than twenty years. He has been under my care for four- 
teen years. At first the wax hardened at intervals of months, but now, espe- 
cially in the summer, the intervals are so short, that the patient is obliged to 
present himself once a month for examination, and generally for the removal of 
the plug that has formed in one or both ears. 

Five years ago, the hardening of the wax was followed by ulceration of the 
outer layer of the membrana tympani. This healed under the use of nitrate of 
silver. A few months after, a granulation was found at the bottom of the canal, 
and an attack of pain occurred. The canal became red and swollen at the junc- 
tion of the auricle and the mastoid. The canal and drum-head were again 
treated by the warm douche, and in a few months the wax again accumulated 
and hardened. A year after the patient again had an abscess in the right ear. 
Although the wax hardens in each ear, inflammation has as yet only occurred 
in the right one. This probably perforated the drum-head, but it healed 
again. 

The inflammation extended from the canal inward, and hence it was not so 
easy to decide as to whether it had passed through the layers of the drum-head 
or not. The last inflammation that as yet affected the ear, in conjunction with 
the impaction of the cerumen, occurred a year and a half ago. This did not 
perforate the drum-head, and healed under the use of iodoform. The patient 
now comes for examination every few weeks, in summer especially, and by re- 
moving the wax before the plug has formed, we hope to prevent the recurrence 
of inflammation. After a careful study of this case, I have not been able to 
satisfy myself as to what causes the wax to harden. 

That the inflammation follows, rather than causes the inspissation, seems to 
be true here. The patient is a gentleman of excellent, even vigorous general 
health, whose habits are correct, and whose position in life enables him to take 
the best of care of himself in every respect. I have tried in vain, to prevent the 
accumulation of the wax by pencilling the canal with nitrate of silver. 

It ought finally to be stated, that although the hearing has often been much 
impaired for some time, it as yet remains practically normal, except when the 
patient is suffering from a recurrence of impaction of cerumen. 



EFFECTS OF QUININE UPON THE EAR. 160 

The following case, which may be considered a remarkable 
one, illustrates not only the etiology of inspissated cerumen, but 
also the effect of quinine upon the ear ; and I insert it as much 
to show the influence of this agent upon the auditory apparatus, 
as for its bearing upon the subject now under discussion. 

It has already been published, 1 but I think it worthy a wider 
circulation than it has hitherto obtained. 

Case V. — Inflammation of the Auditory Canal, caused by Quinine — Impaction of 
Cerumen — Use of Nitric Acid to effect Removal. — On the 3d of May, 1870, I was 

consulted by Dr. N , aet. 34, on account of his throat and ears. He stated 

that he had had acute pharyngeal and laryngeal disease some ten years before. 
He also informed me that neither he nor his parents have any recollection of any 
serious difficulty with his ears prior to the date of the attack, from whose con- 
sequences he is now suffering. The laryngeal inflammation was followed by 
chronic naso-pharyngeal catarrh, and in 1863 he was obliged to take five-grain 
doses of quinine for some weeks on account of nervous prostration from malarial 
fever contracted in the Southern States. These doses were increased to ten 
grains, and cinchonism was produced. The symptoms of cinchonism were, ring- 
ing in the ears and dizziness. In 1864, the doctor again took quinine until the 
constitutional effects were produced, the dose finally reached being twenty to 
twenty-five grains, which was taken every other day. While employing the 
quinine in this manner a severe attack of otitis occurred. The patient states 
in a written history taken from his diary that he recovered from the otitis under 
antiphlogistic treatment. 

After recovery from the aural disease, Dr. N was obliged to resort to the 

use of the quinine on account of the constitutional disease — a severe malarial 
neuralgia. He took one dose of fifteen grains, which was followed by pain in 
the ears. Several efforts were made to return to the use of the quinine, but pain 
in the ear supervened on each dose. "From this period, February, 1865," to 
quote the exact words of the patient, "my ears began to give me constant trouble. 
I was incessantly annoyed by unnatural noises, which would frequently reach 
such a pitch, for a few moments, as to exclude all other sounds." The naso- 
pharyngeal disease also increased, and in March, 1865, he was seen, on account 
of the state of his ears, by a distinguished practitioner. The throat was consid- 
ered the origin of the aural affection, and it was accordingly treated, and was 
improved ; but the ears remained in the same condition, that is, they were sensi- 
tive and affected by tinnitus, and there was some impairment of hearing. 

After the pharynx had been treated, until July of this year (1865), and while 
undergoing treatment, another attack of otitis media occurred, which was pre- 
ceded by five weeks of facial neuralgia. The use of quinine for the relief of 
these attacks had been avoided ; but at last, the patient, worn out by pain, took 
a fifteen-grain dose of the sulphate, upon which the ear disease immediately 
supervened. The quinine was taken on July 30th, and the attack of otitis media 
occurred on the next day. The otitis was of so severe a character as to place the 
doctor in a very depressed condition, and when he recovered from this and the 
neuralgia, which he did simultaneously, to use the patient's mvn language, he 
was "a perfect wreck." 

1 Transactions of the American Otological Society, L873. 



170 EFFECTS OF QUININE. 

He then sailed for Europe, and in the Scotch Highlands recovered from the 
malarial disease, never having suffered from it since up to the present time. The 
ears, however, became very sensitive to the air, and cotton plugs were resorted 

to, and Dr. N has never from this time been able to leave the meatus open, 

even while in-doors, until the past week. The hearing power was also greatly 
impaired while in Scotland ; the patient therefore went to the south of France, 
where his ears were still troublesome. The aural symptoms were tinnitus, a 
sense of pressure in the auditory canal, and frequent attacks of neuralgia of the 
fifth pair. The intellect also became somewhat obscured. After a year's stay 

abroad, Dr. X returned home, when the naso-pharyngeal catarrh returned. 

He then, under the advice of a physician, began the use of the nasal douche for 
its relief, taking all the precautions that are enjoined, using a wann solution of 
common salt in water. It was observed, however, that in an hour or two after 
using the douche, there was an uncomfortable sensation in the ears which became 
more prominent after each application. The physician then advised "less press- 
ure " in the use of the douche ; but the next application was followed by severe 
pain, and this method of treatment was abandoned. The patient was then suffer- 
ing from what was called an inflammation of the auditory canal ; all treatment 
was given up until September of this year, when another attack of otitis media 
and of facial neuralgia occurred. The next two years were spent in Italy. 

The general health of the patient was then excellent, but the hearing did not 
improve, and the patient was obliged to use the cotton plugs. Returning to 
America in the spring, the naso-pharyngeal catarrh, which had not appeared 
while in Italy, returned, and in April, pain occurred in both ears, for which he 
ivas treated by leeches, diaphoretics, and hot fomentations ; after this attack the 
patient describes himself as totally deaf — unable to distinguish the loudest 
sounds. " There was a feeling of spasmodic constriction, and fulness invading 
the cavity of the tympanum, and a sensation of pressure upon the drum- head." 
On the third day the j)atient became able to hear what was said to him, if the 
words were spoken very loudly and with the mouth applied close to the ear ; as 
time passed he became still more improved, so that he could hear conversation 
addressed specially to him at a short distance, and a watch usually heard at four 
feet, at a distance of two inches on each side, H. = - 4 \-. 

This was his condition when he first came under my observation, on May 3, 

1870. I found that the general nervous system of Dr. N , from his years 

of suffering, was in a highly sensitive condition. His pharynx was highly con- 
gested, the uvula very long, and both auditory canals were extremely sensitive 
and plugged with hard wax. For two weeks the patient was under my care, 
during which time I cut off the uvula, and made many attempts to remove the 
impacted wax by syringing, and the use of the forceps ; but in all these attempts 
I failed, in consequence of the hardness of the cerumen and the tightness with 
which it was held by the auditory canal, and also because the ear was extremely 
tender to the slightest touch. 

At the end of this time, the patient was suddenly called to Minnesota, and I 
did not see him again until June 26, 1872, when he presented himself and gave 
the following history of the time that had elapsed. The very small quantity of 
wax removed, and the cutting off of the uvula, had relieved the pharynx and ears 
to some slight extent, and, the climate being adapted to his condition, he did 
very well, except that the hearing was impaired. 

On June 18, 1871, another attack of otitis occurred, which caused some con- 



INSPISSATED CERUMEN. 171 

siderable discomfort, although it was a less severe attack than those which had 
preceded it. The otitis again occurring, the patient came to me, on the date 
above mentioned; more than two years from the first visit. I found him suffering 
severe pain, for which he was taking anodynes ; the ears were about in the same 
state as when I last saw him. The hearing distance was about -fa, the canals were 
plugged with hardened wax ; the patient appeared in fair physical condition, but 
mentally he was excited and slightly irritable and depressed. 

I proceeded to remove the impacted wax, and that from the right ear came 
away on the second day. It was so tightly wedged in that the removal, which 
was effected by the syringe and forceps, caused severe pain, although the walls 
of the canal were not touched. On the fifth day, after the use of various agents 
to soften the mass of cerumen in the left ear, I burned it with nitric acid, and 
then succeeded in removing it. This removal also caused great pain. The 
membranae tympani were suppurating, that is, the outer layers, and they were 
somewhat sunken, especially along the handle of the malleus. The use of a 
solution, nitrate of silver 40 gr. ad § j., and inflation by Politzer's method, soon 
restored them to a normal appearance, except that the curvature remained al- 
tered. The sensitiveness of the ears was removed, so that they could be touched, 
applications made to the drum-head, and so on, without producing any unpleas- 
ant sensations. The hearing distance became - 4 a 8 - on the right side, and was im- 
proved on the left, but to what extent I do not know, not having seen the patient 
for some time. He became able to sleep without an anodyne. The cotton plugs 
which had been worn for years were now removed, and he became altogether a 
different person, as regards his mental condition. 

I think we must regard the otitis in this case, although to a 
certain extent dependent upon the naso-pharyngeal catarrh, as 
chiefly caused by the use of quinine. By looking at the history, 
and observing how promptly and invariably the pain in the ears 
occurred in several instances after the use of the agent, we are 
forced to the conclusion that quinine was the exciting cause of 
the aural inflammation. At what date the impaction of wax 
occurred, we cannot positively determine. I am disposed to be- 
lieve that it was at the time the patient awoke profoundly deaf. 
in April, 1870, or more than two years before it was removed. 
The wax was certainly there one month after, in May, 1870, when 
I first saw him. 

The condition of the patient's mind is illustrated by the fact 
that he allowed two years to pass away with no attempt to 
remove a foreign body, from whose partial removal he had ob- 
tained some relief, and which he believed to be one of the causes 
of his impaired hearing. I can only partially account for this 
delay, by supposing that my efforts at softening and removing 
the mass had so far succeeded as to lift the cerumen from the 
drum-head, and thus gave partial relief. Indeed, the plug, which 
I took out on the second day. was on its way out, and would. I 
think, have soon escaped spontaneously, with one of the loud 



172 INSPISSATED CERUMEN — CASES. 

reports with which hardened wax sometimes shoots from the 
auditory canal. The structure of the plugs was that usually 
found, that is, cerumen in layers ; but there was some epidermis 
exfoliated, and also some pus between the mass of wax and the 
canal. 

The case seems to me to be one of those which have been 
reported, where inflammation of the integument lining the canal 
was one of the causes of impaction of wax, and it may be a con- 
tribution to the etiology of that disease. The earlier history also 
illustrates the effect of quinine upon the ear, which I believe is 
sometimes an inflammation of the conducting portions, as well 
as of the acoustic nerve or labyrinth. We have long suspected 
the latter effect, but the former has not been often observed. 

The following case occurred in my clinic at the Brooklyn Eye 
and Ear Hospital, and was reported by Dr. David Webster, 1 who 
was then House Surgeon. 

It illustrates the serious inflammatory trouble that may be 
caused by inspissated cerumen, a fact which has been already 
alluded to in this chapter, for there is no doubt in my mind, that 
while the impaction of cerumen is sometimes caused by inflam- 
mation, that it in turn may produce ulceration — by mechanical 
pressure. 

Case VI. — Pain — Tinnitus — Deafness — Inspissated Cerumen — Suppuration of 

the Canal — Incisions — Recovery. — D. H , aged 28, laborer, presented himself 

at Dr. Koosa's clinic, at this hospital, November 1, 1870. Five days previously 
his right ear was attacked with pain, tinnitus, and deafness, which symptoms 
had gradually increased up to date. He had slept but little for the last two 
nights, in consequence of the severity of the pain. He could hear the ticking of 
an ordinary watch at the distance of only one inch. 

Upon examination we observed a little puffiness of mastoid process, and some 
swelling back of the angle of the lower jaw and of the walls of the meatus. 
There was also some pharyngitis. Through the aural speculum the external 
meatus was seen to be plugged with hard wax. This was removed by carefully 
syringing the ear with warm water. Some pus was found in the canal, and at 
first the membrana tympani was thought to be perforated, but upon more care- 
ful examination it was found to be intact, though a complete examination of it 
was rendered impossible by the narrowing of the meatus consequent upon the 
swelling. 

Politzer's method for inflating the middle ear was practised, and the patient 
was directed to fill his ear frequently with warm water. 

November 2d. — He said that the pain was so relieved that he rested well 
last night, and complained more of a sensation of soreness than of pain. The 
tinnitus and swelling were undiminished, but the hearing distance had risen to 
ten inches. On using 'Politzer's method, the patient felt the air enter neither 

1 Medical Record, vol. v. , p. 536. 



INSPISSATED CERUMEN — CASES. 173 

ear, and when this was clone again, with the addition of the vapor of chloro- 
form, the air was felt only in the left. He was directed to continue the use of 
warm water. 

November 3d. — The swollen walls of the meatus had become more sensitive 
to the touch, and the pain had returned. He was treated by means of the warm 
aural douche, Politzer's method again used, and the entrance to the meatus 
stuffed with cotton in order to exclude the cold air. 

November 5th. — The swelling had increased. Dr. Prout, who saw the pa- 
tient for Dr. Eoosa, made two incisions in the walls of the meatus — one back- 
ward, the other upward. Pus followed the knife in the latter. The pain caused 
by the incisions was immediately relieved by the warm douche (Clarke's aural 
douche). 

Dr. F. M. Pierce, 1 of Manchester, England, reported a case 
where the symptoms, arising apparently from inspissated ceru- 
men, were more severe than any I have ever seen in my prac- 
tice, yet from the severity of cases which I have seen, I can 
well imagine Dr. Pierce's case. 

Four days before Dr. Pierce saw the patient — a chemist, age not stated — he 
had a severe earache after taking a cold bath, which soon became a diffused in- 
cessant pain over the whole head and neck, with nausea, vomiting, and fever. 
His case was regarded as one of cerebral inflammation until the fifth day of his 
illness, when Dr. Pierce saw him and examined the ears. The watch was not 
heard on that side, while a tuning-fork placed on the head was heard only on 
that side. The walls of the canal were swollen and congested, and there was 
impacted wax. This was removed piecemeal by the forceps, syringe, and a warm 
lotion was dropped into the ear. The next day the patient was free from pain, 
fever, and nausea, and he could hear the watch two inches. After syringing the 
ear (clearing out the remains of the wax ?), the watch was heard thirty-six inches, 
and the patient fully recovered. 

Dr. Pierce suggests, and I suppose the reader will agree with 
him, that the cold water in the canal set up a diffuse inflamma- 
tion, which was favored by the presence of a hard foreign body. 
which was probably not fully impacted when the water got into 
the ear, but which became so, and increased the inflammatory 
symptoms. 

In many cases it will be necessary to treat the auditory canal, 
after the removal of the wax, for a diffuse inflammation. I 
then use a solution of nitrate of silver of say twenty grains to 
the ounce, pencilling it upon the canal, especially at the junc- 
tion of the cartilaginous with the osseous portion, every other 
day, until the normal condition is restored. 



Medical Times and Gazette, March 30, 1S7S. 



174 INSPISSATED CERUMEN. 



STATISTICS. 

One hundred and fifty-three of the 339 cases mentioned on 
page 157 as treated by me in private practice, were plainly also 
affected with other diseases of the ear, as follows : 

Chronic catarrh of the middle ear 79 

Subacute catarrh of the middle ear 11 

Chronic proliferous inflammation of the middle ear 19 

Chronic suppuration of the middle ear 14 

Inflammation of the external auditory canal t 13 

Eczema 5 

Foreign body 1 

Parasitic inflammation of the external ear , 1 

Acute catarrhal inflammation of the middle ear 3 

Disease of acoustic nerve 3 

Other complications 4 

153 

It will be seen that about one-third of the cases seen in my 
private practice, were plainly accompanied, if not caused by 
aural inflammation. I am bound to say, that this proportion 
would have been largely increased, had I earlier in my practice 
given as much attention to the study of inspissated cerumen as 
I now do. It was easy, especially when the patients who were 
relieved by the removal of a large plug of cerumen said they 
heard perfectly, "had no more trouble," were "in a new world,'' 
and so forth, to conclude that their delight at their recovery 
from the fulness, pain, and impairment of hearing was founded 
upon a complete cure of the aural lesion. A little more thorough 
examination often shows, however, that the wax is but the most 
striking symptom of an insidious process that will finally, unless 
checked, destroy all useful hearing power. 

Of a total number of 10,100 aural cases treated at the Man- 
hattan Eye and Ear Hospital in thirteen years, 1084 were clas- 
sified as impacted cerumen. I am not able to state with exact- 
ness how many of these were plainly connected with other 
forms of aural disease, but that a large proportion were, I am 
certain. 

COMPOSITION AND FUNCTIONS OF CERUMEN. 

According to J. E. Petrequin, 1 cerumen is of a smeary con- 
sistency, on account of the soapy material made by the potash 

1 Archiv fur Ohrenlieilkunde, Bd. V., p. 230, from Comptes Rend, de l'Acad. des 
Sciences, xvi., pp. 940, 941. 1869. 



COMPOSITION OF CERUMEN. 175 

which it contains. A part of it is soluble in water, another in 
water and alcohol. It also contains, according to the same au- 
thority, about one-tenth per cent, of water, a mixture of oil and 
stearine, and a dry material not soluble in water, alcohol, and 
ether, in which potash, and traces of chalk and soda are found. 
As age advances, the parts of the cerumen that are soluble in 
water and soluble substances increase, but those soluble in alco- 
hol diminish ; so that in older persons the cerumen becomes dry 
and brittle. 

Kessel's account of the cerumen is as follows ] : The contents 
of the ceruminous glands only differ from those of the sweat 
glands in the fact that the former contain masses of very fine 
coloring matter. The substance secreted by the ceruminous and 
sebaceous glands together, is a yellowish -white, rather fluid 
material, which consists essentially of small and large fat glob- 
ules, corpuscles of coloring matter in masses, and cells in which 
single globules of fat and coloring matter are embedded ; hairs 
and scales of epidermis from the lining of the canal are also 
found in the canal. 

Those who are curious in regard to the opinions of the last 
century and the early part of the present one, on the subject of 
the functions of the cerumen and the affections of the ear caused 
by the suppression of the secretion, will find the book of Thomas 
Buchanan, 2 of Hull, interesting reading. Mr. Buchanan ascribed 
most of the diseases of the ear to impaction of cerumen or stop- 
page of its secretion. He believed that it had a very important 
function in relieving the harshness of the waves of sound. If it 
were not for the lining of cerumen which is in the meatus, the 
waves of sound would fall irregularly upon the drum membrane 
and cause it to vibrate unevenly. Mr. Buchanan also explained 
Mr. Everard Home's case of double hearing by his theory of defi- 
cient secretion of the cerumen. It was that of a music teacher, 
who found that after a cold the pitch of one ear was half a note 
deeper than the other, and that a sin* one w^as not recognized 
as one by both ears. This is a specimen of the author's fanciful 
notions about the important functions of this lubricating and 
protecting secretion. 

Strieker's Manual: The External Ear, by Kessel, translated by J. Orne Green, 
p. 951. 

2 Physiological Illustrations of the Organ of Hearing, more particularly of the Secre- 
tion of Cerumen, and its effects in rendering auditory perception accurate and acute. 
with further remarks on the treatment of diminution o( hearing, arising from im- 
perfect secretion, etc. Being a sequel to the Guide and to the Illustrations of Acoustic 
Surgery. London, 1828. 



176 INSPISSATED CEKUMEN 

He makes a disease — Tubulus Hirsutus — of the growth of 
hairs in the canal, saying that no one with acute hearing has 
hairs growing over the surface of the membrana tympani. He 
also tells a singular story of a man who became very deaf, in his 
opinion from years of loud talking to a deaf wife. He imagined 
that the continued screaming at last lessened the sensibility of 
the portio mollis. 1 

The function of the ceruminous glands, is probably that of the 
sudoriparous glands. They keep the parts in which they secrete 
pliable, and also prevent the ready admission of insects. There 
is no evidence that the cerumen has anything to do with the reg- 
ulations of the intensity with which the waves of sound reach 
the ear. 

Hallucinations have been in rare instances relieved by the 
removal of inspissated cerumen. Professor Mayer, formerly 
director of the Insane Asylum at Hamburg, is the authority for 
this statement. 2 

I once saw a lady who, though not regarded as a person of 
unsound mind, seemed to be such, and who complained greatly 
of tinnitus aurium in all its varieties. I found the ears full of 
impacted cerumen ; but she utterly refused to allow me to remove 
it, and I never saw her but once. It would have been very inter- 
esting to know the effect of the relief of the tinnitus upon the 
hallucinations of which she seemed to be a victim. Epilepsy has 
been said to be cured by the removal of hard wax from the ear. 
It will be seen, by reference to the following chapter, that it 
may cause ear cough and ear sneezing. 

1 A good synopsis of Buchanan's book will be found in Lincke's Sammlung aus- 
erlesener Abhandlungen und Beobachtungen aus dem Gebiete der Ohrenheilkunde, 
Bd. III. Leipzig, 1836. 

2 Troltsch on the Ear, second edition, translation, p. 531. 



CHAPTER VIII. 

FOBEIGN BODIES. 

Exaggeration of the Importance of this Subject. — Statistics. — Insects. — Living Lar- 
vae. — Fish. — Inanimate Foreign Bodies. — Treatment. — Delusions as to Foreign 
Bodies in the Ear. — Foreign Bodies in the Eustachian Tube. — Ear Cough. 

In entering upon the discussion of the subject of foreign bodies 
in the ear, I desire to express the conviction that its impor- 
tance has been often exaggerated. The reader of medical jour- 
nals, who has not given any special attention to diseases of the 
ear, must be surprised to find this subject figuring so largely in 
literature, when he knows that the general practitioner of large 
experience sees but very few of such cases, even if he lives 
remote from specialists and surgical experts. The reports of 
hospitals and infirmaries for diseases of the eye and ear also 
show that the entrance of a foreign body into the auditory canal 
is brought to the attention of the attending surgeons with com- 
parative infrequency. 

The following table shows this : 

Total number Number of cases 

of aural of foreign 

cases. body. 

1882. 1882. 

New York Ophthalmic and Aural Institute 1057 8 

Massachusetts Eye and Ear Infirmary, Boston 2636 21 

Salem Hospital 74 

Presbyterian Eye and Ear Hospital, Baltimore 788 2 

New York Eye and Ear Infirmary 2889 32 

Syracuse (N. Y.) Eye and Ear Infirmary Ill 1 

St. Michael's (Newark, N. J.) ' 190 1 

Manhattan (New York) Eye and Ear Hospital 881 2 

Philadelphia Dispensary (Eye and Ear Department) .... 1441) i\ 

Brooklyn Eye and Ear Hospital 273 9 

Newark Eye and Ear Infirmary (1880) 877 lti 

11,216 101 

In the Manhattan Eye and Ear Hospital for thirteen years. 
76 cases of foreign bodies in the oar have boon presented foi- 
ls 



178 FOREIGN BODIES. 

treatment, and 2 of supposed foreign body. In my private prac- 
tice in 4800 cases there were 26 of foreign bodies, and 4 in which 
the patient or friends supposed there was one, and yet none was 
found. 1 These statistics show that foreign bodies in the ear, are 
not as frequently seen by the surgeon, as the inexperienced prac- 
titioner might be led to suppose. 

But my opinion that the importance of the subject has been 
exaggerated, by the great mass that has been written upon it, 
is not founded altogether upon the relative infrequency of the 
cases. If cases, that are comparatively uncommon, are still very 
dangerous, in nearly every instance when they do occur, the 
medical teachers have a right to call attention to them as being 
very important and to dwell upon them, even at the risk of 
wearying their listeners and readers. But foreign bodies in the 
auditory canal as a rule, are not dangerous. In this respect they 
have none of the importance of foreign bodies within the eyeball. 
Foreign bodies in the tympanic cavity, are necessarily dangerous 
and destructive to the functions of the ear, but in the vast major- 
ity of cases of foreign bodies in the ear, the foreign body is this 
side of the drum-head. 

This much is said by way of introduction, with the hope 
that it will enable the practitioner who may consult these 
pages, to enter upon the management of a case of foreign 
body in the ear, when it comes to him, with coolness and with- 
out fear that he has one which will brook no delay, and which 
will tolerate no mere palliative means, without danger to the 
hearing or the life. 

The usual point of entrance of foreign bodies into the ear, 
is through the external auditory canal. They sometimes pass 
beyond this part and become lodged in the cavity of the tym- 
panum, or Eustachian tube, while in some rare instances a for- 
eign body has entered the ear through the Eustachian tube. I 
have therefore entitled this chapter " Foreign Bodies," so that 
I might properly include all such cases in the descriptions that 
are about to be given. 

The foreign bodies that are found in the auditory canal, are 
very naturally placed under three heads : insects, or the like, 
which creep into the passage ; their larvse, which are generated 
there ; and various articles, such as beads, buttons, peas, beans, 
and so on, which are pushed into the ear by children or silly 
adults, or which may be thrown into the ear. 



1 Buckner's statistics, made up from various authorities, show that of a total of 
43,730 cases, 670 were cases of foreign bodies. Archi.v f iir Ohrenheilkunde, 1883. 



INSECTS. 179 



INSECTS. 



When a live insect gets into an ear, the pain produced is 
usually intense and agonizing. Insects are more apt to get into 
the ears of sportsmen while hunting in thicket and underbrush, 
and of farmers laboring in the field, than of dwellers in cities 
and towns. Yet, on the hot days of summer, when insect life 
is very active, the city practitioner will sometimes be called to 
remove a bug from the ear, if the agony induced by the foreign 
body do not stimulate some of the family to a successful at- 
tempt at its removal. 

There is an insect, which lives on the leaves of fruits and 
flowers, and which, like others, sometimes flies into the ear, 
which is called an ear-wig, and there was an ancient supersti- 
tion that it crept into the brain through the ear. The forflcula 
auricular is, or so-called ear-wig, has probably no more propen- 
sity to fly into the ear than any other insect ; any of the ordi- 
nary flies may do so. 

I have seen a few cases of cockroaches in the ear, as well as 
croton bugs. I have never had any difficulty in removing them. 
In some instances they die in the ear, and then they become the 
nucleus for the collection of cerumen about them. 

The most efficient and the speediest means of removing an 
insect from the ear is the use of a syringe and warm water. As 
little animals usually get into the ear when the patient is in the 
fields or forests, where physicians are not always at hand, lay- 
men should be taught, in the case of the occurrence of such an 
accident, to immediately pour water or any bland fluid in the 
meatus. This will disturb the animal and either drown it or 
cause it to run out. 

Some writers advise the use of an oil dropped into the ear 
before the water is used, but Wilde and Troltsch agree that this 
is an unnecessary waste of time. In all the cases I have treated. 
the insect was promptly dislodged by the use of the syringe, and 
I have no doubt that the simple filling of the auditory canal 
with water, will cause insects to come out at once. 

LIVING LARVAE IN THE EAR. 

Insects sometimes deposit their eggs upon the pus of a sup- 
purating ear. According to Wood, who is quoted by Blakej 1 
insects have a very acute sense of smell. '*No flock of vul- 



1 Living Larva* in the Unman Lar. Archives of Ophthalmology and Otology, Vol 
II., No. 2. 



180 LIVING LAKV.E. 

tures can be directed more unerringly to their revolting prey by 
scenting its odors from afar." 

The odor of an otitis media purulenta, thus brings the insect 
to deposit its eggs in the auditory canal and cavity of the tym- 
panum, where they soon become grubs or larvae. 

These larvae always excite considerable, and sometimes very 
severe pain, but in the cases which I have seen, the patients 
complain much more of the wriggling movements of the grubs 
in the ear, than of the pain. 

The ancient works on aural diseases speak very much of 
worms in the ear and of the proper means of removing them. 
It is probable, that these so-called worms, were the larvae of 
insects which germinated from eggs deposited in the pus of a 
chronic suppurative process. Certain it is, that the practitioner 
of the present time, sees very little of worms in the ears, since 
the habit of cleansing an ear from pus, has become a well- 
recognized duty. The pain from the presence of these grubs, 
which actually fasten themselves, when hatched, into the tissue 
of the canal, and bite upon it, as it were, is apt to occur sud- 
denly. An Austrian physician, Dr. Scheibenzuber, 1 reports a 
case of a peasant ploughing in the field, who was seized in an 
instant, with a severe pain in the ear, which he ascribed to the 
flying in of a bug, but the surgeon found the ear full of well- 
developed larvae. 

I have several times observed dead insects, in the pus that 
was washed out from an external auditory canal, and it is un- 
doubtedly true, as I have already suggested, that we should, 
equally with the ancients, have many cases of living larvae in 
the ear, were it not that suppurating ears are usually now- 
a-days regularly cleansed. 

The larvae that have thus far been found in the ear are those 
of the muscida sarcophaga (Blake, Gruber), and of the muscida 
lucilia (Blake). Dr. Blake 2 has made a study of the nature and 
habits of these grubs, by taking them from the ear at a very 
earry period of development ; as near as could be ascertained 
within twelve hours of the time of their deposit. He placed a 
specimen on the bottom of a thin glass vessel, and covered it 
with a piece of raw beef, soaked in warm water, in such a man- 
ner that by inverting the glass the movements of the larvae 
could be easily studied under the microscope. Dr. Blake found 
that the apparatus by which the larva attaches itself, and which 
pierces and tears the tissue, is made up of a strong but delicate 

1 Monatsschrift fur Ohrenheilkunde, Jalirgang III., No. 3. 

2 Archives of Ophthalmology and Otology, loc. cit. 



LIVING LAEV.E. 181 

framework of horny consistency and of two hooks also of a 
stout horny structure, articulating with this framework. The 
larva burrows its way into the tissue on which it feeds by re- 
peated extension and contraction of the hooks, alternately pierc- 
ing and tearing. These movements explain the agonizing pain 
which patients experience when the larvae appear from the 
eggs. These hooks are very large in proportion to the size of 
the body of the larvae. 

Dr. Blake says that the instincts of the animal lead it to bury 
itself beneath the surface, and to seek warmth and moisture 
and a soft, yielding tissue for its work. Hence they are always 
found at the end of the canal, or in the cavity of the tympanum. 
As yet, they have always been found in connection with sup- 
puration of the middle ear, with its consequent perforation of 
the membrana tympani. 

The examination of the auditory canal infested by living 
larvae, shows small white worm-like animals moving rapidly 
about, very much as a mass of common earth-worms. As I 
write, I have before me a number of specimens of the dead 
grubs. They are about half an inch in length, and of the 
diameter of a large knitting-needle. 

Dr. Gruening reported at a meeting of the New York Oph- 
thalmological Society, in 1882, a case of living larvae in the 
auditory canal when the tissues were sound, but his case is as 
yet unique in literature, I believe. 

Very small fish, have been known to enter the auditory canal 
while the victim was bathing. One of my patients, a lady, gave 
me a minute account of such an occurrence to herself. The 
little intruder caused great pain for some hours, and finally 
came out spontaneously. In the Reading (Pa.) Eagle of July 9, 
1880, there is a circumstantial account of a case of the entrance 
of a fish two inches long, into the ear of a boy of fourteen, while 
he was bathing. According to this account, he suffered for 
two weeks from intermittent and severe pain. As his parents 
thought it was "only an earache," no physician was called. 
Laudanum, rabbits' fat, and molasses were among the remedies 
used for the two weeks that the boy was suffering intolerable 
pain, which greatly reduced his strength. The mother of the 
boy, finally, in one of his fits of pain, wound a handkerchief 
around the head of a pin and probed the ear. " She saw some- 
thing protrude," and got hold of it and pulled it out. when it 
proved to be a living fish of the length above stated. The lady 
who, while she was under my care for aural affection of another 
kind, told me of her sufferings from the entrance of a small fish 
into the auditory canal, also said that the pain was so decidedly 



182 LIVING LARVAE. 

intermittent in character, she being for some hours at a time 
without pain, that she could not believe anything animate in 
her ear was causing the trouble. 

Treatment. — I have found it impossible to remove living larva3 
by means of the syringe. The more they are syringed the more 
lively they become. Before the syringing is attempted, some 
agent should be instilled into the ear which will kill them, when 
the syringe will usually remove them. Sometimes, however, 
even after death, their hooks penetrate so deeply into the tissue 
that they can only be removed with the forceps. The forceps 
should not be needlessly used, however, for even with the most 
careful manipulation, and with tractable patients, they often 
abrade the integument of the canal, and thus cause pain. I 
have used Labarraque's solution of chlorinated soda, to kill these 
grubs, but simply because it was at hand when I saw the cases. 

The larvae have also been killed by forcing the vapor of 
chloroform into the cavity of the tympanum through the Eusta- 
chian tube. I believe, however, that it will be sufficient to force 
the vapor into the external ear, or to instill some such fluid as I 
have mentioned into the canal. 

It need hardly be said, that the disease which allowed of the 
deposition of the eggs, and the hatching of the grubs, should be 
treated after they have been removed. Even those who arc 
advocates of allowing a discharge from the ear to remain un- 
checked, will hardly defend such a neglect when the ear has 
become a disgusting receptacle in which larvae are formed. 

INANIMATE FOREIGN BODIES. 

The foreign bodies that are placed in the ears of children by 
themselves or their playmates, have, from the time of the first 
writers on otology, formed a fertile field for the labors of sur- 
geons. From some source or other, the laity have got the im- 
pression that a foreign body in the ear, like a wild beast acciden- 
tally let loose upon a civilized community, is to be hunted down 
at all hazards. The presence of a foreign body in the canal is, 
after all, however, not a very serious matter. Children do not 
usually push them in far enough to do any harm. It is the 
meddlesome interference of nurses and friends, and sometimes 
of unwise practitioners, that forces them into dangerous posi- 
tions. There was a notion prevalent in England, in Shakspeare's 
times, 1 that poison poured into the ears was as dangerous as if 

1 Hamlet, Act III., Scene 2. 



INANIMATE FOREIGN BODIES. 183 

taken into the stomach ; and from this, in some manner or other, 
has come the idea that a foreign body in the ear becomes at once 
a very dangerous thing. 

It would be well, if this fear of foreign bodies in the ear, 
were transferred to cases where they have entered the eyeball, 
where the most serious results do occur from the neglect to 
promptly remove a foreign substance. Unskilful or indiscreet 
attempts to remove a foreign body from the ear, are often more 
dangerous than the foreign body itself. In the case of a foreign 
body in the eye, it is the loss of sight that is threatened, and it is 
usually the worst that can happen ; but it is not a very rare ex- 
perience, that improper attempts to remove a foreign body from 
the ear, have cost the life of the patient 

When, therefore, a child is brought to the practitioner, in 
whose ear there is, or there is supposed to be, a foreign body, let 
him first, by ocular examination, be sure that the diagnosis is 
correct, and then let him attempt to remove it by a safe means. 

" First catch your hare," is the quaint and familiar beginning 
of the old receipt for cooking this animal ; and in imitation of 
this sage advice, the writer, taught by experience that the diag- 
nosis of mothers and nurses is not always to be trusted, would 
urge upon his readers the wisdom of not attempting to remove 
a foreign body which he cannot see. There is nothing more 
deceptive than the tactile examination. Again and again, have 
I seen physicians click with a probe, what they supposed to be 
a foreign body, when they were simply striking the bony wall 
of the canal. The surgeon should not take the testimony of 
the most intelligent nurse in the world, as to the presence of a 
foreign body in the ear, unless he sees it himself. Such testi- 
mony is only valuable to prove that a foreign body was once in 
the ear. Any attempt to remove a foreign body that is not seen, 
but which is supposed to be in the ear, will usually lead to a dan- 
gerous and mortifying failure. Even when it is seen, a forcible 
or violent attempt is always a dangerous procedure. 

Voltolini, 1 in writing on this subject, says, "that even the 
point of a dagger, if, allowed to quietly remain in the ear, will 
not do as much harm as forcible attempts to remove it." 

The danger to be apprehended from attempts to remove a 
foreign body by the use of force is, that it will be pushed down- 
ward in the ear, and through the membrana tympani into the 
cavity of the tympanum, and oven into the labyrinth. Unfor- 
tunately for the fair fame of surgical science, such cases are on 
record. 

1 Monatsst'hrift fur 01irenheilkiuhU\ Jftkrgang EL, No, xi. 



184 INANIMATE FOREIGN BODIES. 

Treatment. — If the physician see a case in which a foreign 
body has really got into the auditory canal — a fact which he 
should determine by the use of the speculum and the otoscope — 
before it has been meddled with, he will almost always be able 
to remove it by the process of syringing the ear with warm 
water. Children, however young, will readily submit to this 
operation, and it is almost always successful, if, as I have said, 
there have been no previous manipulations with instruments. 
Unfortunately, however, the cases are not usually seen by a 
physician until the friends of the little patient, having found by 
the child's own statement that a bead, or a pea, or a shoe-button, 
or the like, is in the canal, and having been able to see it, have 
pushed it well in, in their misguided zeal to remove that which 
in itself is not dangerous to the ear or its functions. 

Many cases are on record where foreign bodies, which had 
not occluded the auditory passage, have remained in it for years 
without doing harm. Thus Wreden 1 reports a case in which he 
removed a button from the outer ear, which had remained at the 
junction of the osseous and cartilaginous canal of a boy of seven- 
teen, for twelve years, and without doing any harm. If, how- 
ever, the foreign body has become impacted by the attempts to 
remove it, and if serious inflammatory symptoms have arisen, it 
is better to wait until the latter have subsided before any further 
attempts at removal are made. 

Then, if instruments are to be used, the child should be placed 
under the influence of ether, and by means of a small bent probe 
or hook (a wire loop will often do good service), or the instrument 
used for dividing the capsule of the lens in the operation of ex- 
traction, it should, if possible, be dislodged from its wedged 
position, and then removed by the syringe. No manipulation of 
this kind should be attempted, however, unless the foreign body 
is well illuminated, so that the surgeon can see exactly what he 
is doing during the whole of his manipulations. 

In cases where injections made while the patient is in an up- 
right position, do not remove the foreign body,' Voltolini has 
adopted the following method with success : 

The child is laid upon a table, so that its head may hang a 
little over the end of it. The membrana tympani then forms a 
plane with the upper wall of the auditory canal, that runs ob- 
liquely downward. The syringing is then performed as usual. 
In two cases Voltolini has succeeded in removing the foreign 
body by this manoeuvre, when the ordinary method did not 
succeed. 

1 Monatsschrift fur Ohrenlieilkunde, Jalirgang III., No. 12. 



INANIMATE FOREIGN BODIES. 185 

Voltolini has also used the galvano-caustic in breaking- up 
the so-called Johannis brod, or carob bean. The bean having 
become so firmly wedged into the ear that it was impossible to 
move it one way or the other, he inserted the needle "with 
lightning-like rapidity " into the body, and when it cooled, the 
bean broke with a snap audible to the patient and to those about. 
When sufficiently broken up, it was removed by syringing. 

Foreign bodies, such as peas, beans, and the like, are harder 
to remove after they have been in the ear for some time, than 
metallic bodies, because they swell and thus become wedged 
firmly in the canal, and if they have been pushed into the cavity 
of the tympanum they excite still more trouble and become still 
more unmanageable. 

I have notes of forty-four cases of foreign bodies in the ear 
that have occurred in my practice, and I have never but in one 
case failed to remove the offender, and then I saw the patient 
but once for a few moments. The syringing did not succeed, 
and I asked the mother to bring the patient to my clinic at the 
hospital, where she might be placed under the influence of an 
anaesthetic, but she was not brought. 

In one case, when the child first came under my observation, 
a button was lodged in the cavity of the tympanum by efforts 
to remove it. I syringed it in vain on several occasions. I then 
proceeded carefully with instruments, the patient being anaes- 
thetized. This attempt also failed. I then ordered the mother 
to syringe the ear three times a day, which was necessary on 
account of the purulent otitis media which had been set up by 
the presence of the button in the cavity of the tympanum, and 
I also advised the careful use of poultices. To my delight, in 
about four weeks I had the satisfaction of removing the button 
from the canal, where it had been brought by the syringing and 
the use of the poultices. 

For years, I had under my care, a little child of four years 
of age, who, according to her own statement to her nurse, put 
an ordinary shoe-button, made of papier-mache, in her ear. As 
soon as the nurse's attention was called to the case, she re- 
ported it to the family, who sent for a physician, who saw the 
button, and attempted to remove it, under chloroform, using for 
this purpose a small elevator. It is stated that half the button 
was removed in this way; but the other half could not be dis- 
lodged. 

In a few days, the child having become very weak from the 
operation and the anaesthetic, I was called in consultation. A 
careful examination was made. The membrana tympani was 
found to be gone, there was considerable swelling of the canal. 



186 FOREIGN BODIES. 

but the button was not to be seen either by the physician or 
myself, although he thought he detected it with the probe. 

Another surgeon was called in, and he was not able to find a 
foreign body, and the child was under treatment for years for 
a chronic suppuration of the middle ear, the membrana tympani 
and the ossicula being gone, and the hearing irretrievably in- 
jured. 

I recite such cases, in order to show what harmful conse- 
quences may result, from the most conscientious attempts to 
remove a foreign body with instruments. 

No engravings are given in this volume of the numerous 
hooks, forceps, perforators, drills, picks, et id genus omne, that 
have been devised by surgeons, with more ingenuity than wis- 
dom, for the removal of foreign bodies from the ear, because I 
firmly believe that the vast majority of such instruments are 
very dangerous weapons ; while they are usually greatly in- 
ferior in efficiency to the use of the warm water and syringe. 
Cases will occur, however, in which syringing will not be suf- 
ficient ; but I should not hasten unduly, unless the body had 
become impacted in the tympanic cavity, or was causing un- 
pleasant or serious symptoms. In such cases the ordinary arma- 
mentarium of the surgeon will generally contain instruments 
adapted for the individual cases as they occur. Let him remem- 
ber, however, that once beyond the membrana tympani, he is 
dealing with parts whose injury becomes dangerous not only to 
hearing but to life. 

Dr. Elsberg ' thinks very highly of a delicate double screw 
hook, with two little prongs pointing in different directions. It 
can be introduced into the canal and laid against a sensitive 
part, according to Elsberg, without causing pain or injury. By 
twirling it around from left to right, the prongs will endeavor 
to bury themselves into the substance they rest against ; on re- 
versing the motion it unscrews, taking no hold, or letting go if 
previously fastened. Dr. Elsberg, also uses this instrument for 
foreign bodies in the nose. He only advises its use in the ear in 
exceptional cases, that is, those in which syringing fails. For 
the removal of impacted cotton, such as one case reported by 
Elsberg, 2 I have no difficulty when I use the ordinary angular 
forceps, with delicate teeth. I have never been in the habit of 
classifying all the cases where wads of cotton are pushed down 
to the bottom of the canal, in cases of aural disease, among for- 
eign bodies. They are very common accidents in the treatment 

1 Medical Record. February 1, 1870. 

2 Detroit Lancet, September, 1882. 



INSTRUMENTS FOR FOREIGN BODIIIS. 187 

of aural disease by the patient himself, and hardly seem to me 
worthy of more than an allusion. 

Patients who use Toynbee's artificial drum-head, occasionally 
lose the disk of rubber in the ear, and come to a surgeon for its 
removal. This is usually easily accomplished by the syringe. 
If not, a bent probe may be used to lift up the disk to a situation 
where it can be readily grasped with the forceps. Such patients 
from their experience in this direction, are very tractable and 
tolerant of manipulations in the canal. Consequently the re- 
moval of foreign bodies from their ears is a very simple matter, 
as a rule, certainly as compared with a similar operation upon 
children. Some years after Dr. Elsberg had published his ac- 
count of his instrument, he found that other surgeons, some 
forty years before him, had invented similar instruments. It 
will be found on study of the old text-books, especially those of 
Lincke and Frank, that most, if not all, of the modern inventors 
of instruments for extracting foreign bodies from the ear, have 
been anticipated, and that there remains not much to discover 
in this field. 

For example, Dr. Kinne ' recommends a hook made of a pin. 
Dr. Gross' instrument is essentially this instrument, as is the 
cystotome used in cataract operations and often used by aural 
surgeons. It is passed behind or to the side of the foreign body, 
when it is easily fastened upon, and a dislodgement occurs. 
One of my staff at the Manhattan Eye and Ear Hospital, Dr. F. 
M. Wilson, lately removed a bead from the auditory canal of a 
child by "stringing" it upon a Bowman's lachrymal probe. Dr. 
Wilson intended to use the probe to dislodge the bead, but find- 
ing he could easily pass it into the eye of the bead, he did so. 
Dr. Knapp 2 lays some stress upon the use, in difficult cases, of a. 
flexible silver hook, the concave side of which is roughened and 
hollowed out. Such a hook, it is claimed, is less likely to slip off 
the foreign body. Dr. Knapp adds his testimony to the nearly 
unanimous general statement of experienced surgeons upon this 
subject, that he does not remember a single case in which he 
failed to remove a foreign body by syringing or by the hook. 
The recommendation byPolitzer 3 to use alcohol in the ear to 
avoid swelling of the canal from the prolonged use of water, is 
a good one, and, as Knapp says, it may be enlarged so as to in- 
clude its use for swelling of the canal from the swelling of the 
foreign body itself, since alcohol is such an excellent remedy for 
the shrinkage of proliferating tissue. 



Detroit Lancet, June, 1882. - Medical Record, January, 1383, p. 35, 

:! Text-book, translation, p 638. 



188 DETACHMENT OF THE AUPwICLE. 

The ancient suggestion of Hippocrates, Paul of Mgina, and 
Du Verney, which was revived and re-suggested by Troltsch in 
1802, to detach the auricle from the ear, will be found worthy of 
consideration, when it is found impossible to remove a foreign 
body through the canal. It is not a dangerous operation, and it 
is much to be preferred to any risk of serious injury to the cavity 
of the tympanum or the labyrinth. 

Following the suggestion of Troltsch, I performed the opera- 
tion of detachment of the auricle for the removal of a foreign 
body in April, 1874. In 1881 Dr. J. Orne Green ' performed the 
same operation, and, in 1882, Dr. A. H. Buck. 2 

According to Politzer, 3 it has also been performed by Lan- 
genbeck (Berliner Med. Wochenschrift, 1876), who removed a 
button from the tympanic cavity after partial separation of the 
posterior attachment of the auricle. Moldenhauer, 4 in 1881, also 
removed a stone from the auditory canal of a boy of three and a 
half years of age, after completely detaching the auricle posteri- 
orly. Schwartze adds a note to Moldenhauers article, the latter 
writer having quoted him from Troltsch's text-book, to state 
that he has separated the auricle in three cases for the removal 
of foreign bodies from the ear. Schwartze gives no more exact 
date to his operations than to say, " In the beginning of the last 
ten years," (Aus dem Anfange des vorigen Decenniums). This 
probably means in the years 1872, 1873, or 1871. From all this 
it appears, that either Schwartze or myself, was the first to per- 
form this operation, after it was suggested by Paul von Mgimx 
(see introductory chapter), and re-suggested by Troltsch in the 
first edition of his text-book. 

Schwartze 5 urgently advises against the cutting out of pieces 
of the cartilaginous canal or a partial chiselling out of the pos- 
terior wall of the osseous canal, in order to get a larger field of 
operation in removing a foreign body from the ear. 

The case in which I performed this operation, was that of a 
gentleman, who when about sixteen years of age, was accident- 
ally shot by himself, the shot entering the ramus of the upper jaw. 
The zygoma and the outer wall of the orbit were fractured. The 
auricle was detached and the lower jaw was broken. Twenty-two 
shot were removed from various parts of the face. The auditory 
canal became nearly closed, but there was a constant discharge 
of pus from it. It was evident that the bony canal or tympanic 



1 Transactions American Otological Society, Vol. II., p. 471. 

2 New York Medical Record, December, 1882, p. 676. 

3 Text-book, translation, p. 631. 

4 Archiv fur Obrenheilkunde, Bd. XVIII., p. 59. 5 Loc. cit. 



DETACHMENT OF TPTE AURICLE. 189 

cavity, or both were fractured, for pieces of dead bone came 
away. Granulations sprouted up in the canal, and severe head- 
aches constantly recurred, so that the patient was prevented 
from engaging in business or study. Lead probes were used to 
keep the canal dilated. In 1874 one was lost in the canal or 
tympanic cavity, and all attempts to remove it had failed. 

Then Mr. W came under my care. I used the usual means 

to find and remove the style — Nelaton's probe, sponge tents, and 
so forth — but I was unsuccessful. I was never certain that I had 
found it. The canal was narrow and inflamed, the drum-head 
was gone, and manipulation was difficult. I then determined 
to detach the auricle. The patient was placed under ether, and 
with the assistance of Dr. F. H. Rankin, now of Newport, R. I., 
and Dr. Sturgis, of this city, I separated the auricle from the 
bone posteriorly, and searched for the style. Similarly with 
the experience of Buck and Moldenhauer, I did not find that the 
operation enlarged the field of operation or exposed the tympanic 
cavity, as freely as I had been led to hope. Yet the detachment 
was of very great and essential assistance. The style was not 
found, but a shot ivas removed from the tympanic cavity. The 
wound was united by suture and healed by first intention, the 
facial neuralgia passed away after the removal of the shot, and 
in 1879 the leaden style came away spontaneously, the patient 
all the time taking good care of the purulent affection of the 
middle ear and canal by syringing, and so forth. The shot 
must have made the pressure that caused the neuralgia, since it 
ceased when this was removed. 

The operation of detachment of the auricle, has certainly now 
a sufficient foothold in the experience of surgeons, to relieve it 
from the stigma cast upon it by a distinguished professor, who 
once said that "the idea of separating the auditory canal from 
the squamous process of the temporal bone, with a view of ob- 
taining access to the extraneous substance, as suggested by Von 
Troltsch, is so absurd that it ought to be ranked among the ex- 
ploded notions of the barbarous ages." Another writer, in the 
American Journal of Otology, January, 1881, alluded to the 
operation only to speak of its "utter futility," but in spite of this, 
it is now a sound surgical procedure, based on an experience that 
fully justifies its performance, whenever it may be indicated by 
an inability to get at a foreign body through the canal. 

Dr. Ornc Green performed the operation on May 11, 1881, upOD a man who. 
with suicidal intent, placed the muzzle of a small revolver directly in the right au- 
ditory meatus, and fired two shots in that passage. Three days after, the patient 
was brought, to the City Hospital of Bostou, complaining only of headache, sore- 



190 DETACHMENT OF THE AURICLE. 

ness of the ear and face on the side of the injured ear. The meatus was found 
filled with half-burnt powder, and with a probe loose foreign bodies were detected. 
Three days after admission a semi-circular incision was made above and behind 
the auricle, through the periosteum, and the periosteum with the auricle and 
cartilaginous meatus carried forward until the edge of the osseous meatus was 
reached. Dr. Green then readily seized a loose foreign body, an irregular bit of 
lead. After syringing and digging out masses of powder, the anterior osseous wall 
of the meatus was found to be loose and was removed. A porcelain -tipped probe 
detected a second mass of lead firmly wedged in. This was loosened and removed. 
A third mass of lead, also detected by the probe, was gradually loosened and re- 
moved. The auricle was replaced, the incision united by sutures, and a carbolic 
dressing applied. The patient did well for four days, he then refused to eat, 
became delirious, and died six days af cer the operation. The post-mortem ex- 
amination showed serum beneath thej.Ha mater and congestion. The dura mater, 
pia mater, and brain-substance just over the roof of the tympanum were firmly 
adherent and could not be separated from the bone. Just above, passing into the 
brain for half an inch, was a small sinus, evidently the track of a piece of one 
bullet. There were small bits of bone embedded in the dura mater at this point. 
On examination of the right temporal bone the whole anterior wall of the osseous 
meatus was found to be wanting, the tissues in front of the ear around the glen- 
oid fossa were gangrenous. The roof of the tympanum was perforated by an 
opening 8 mm. long and 4 mm. broad. The bone within the tympanic cavity was 
entirely bare. The ossicles were gone, and the lower edge of the fenestra ovalis 
was broken away. No lead was found in the bone. The lead removed weighed 
in all 48£ grains. Two bullets of the size used would weigh 60 grains, leaving 
llf grains, which in all probability entered the brain. When Dr. Green first ex- 
amined this case, he found that the meatus was unusually small, and this fact, 
with the certainty that if the bullets were found they would be flattened, caused 
him to undertake the operation of detaching the auricle. 

Dr. Green goes on to state, that if one portion of the bullet 
had not glanced upward, and passed through the roof of the 
tympanum into the brain, a condition impossible to diagnosticate 
beforehand, there were no reasons why recovery should not have 
occurred. Langenbeck, by the aid of this operation, removed a 
small button which had entered the left tympanic cavity, and 
caused a very extensive reflex-neurotic pain in the arms, upper 
jaw, with hyperalgesia of the skin of the affected parts, and 
finally contraction of the left hand. The wound healed by first 
intention, except a slight fistula under the parotid. The patient 
recovered in three days from the reflex symptoms. 1 

Dr. Buck's case should also be given, for I am sure a careful 
consideration of this subject, will establish this operation in full 
favor, especially in cases where the foreign body has entered 
the tympanic cavity, and where in addition to this the meatus 
externus and canal are abnormally small. It goes without say- 

1 Troltsch, Lehrbuch, Secliste Auflage, p. 510. Leipzig, 1877. Berlin. Klin. Wochen- 
schrift, 1876, No. 15. 



DETACHMENT OF THE AURICLE. 191 

ing, as Troltsch said when he advised a revival of the operation, 
that it is to be reserved for urgent cases. Yet no surgeon need 
be deterred from it, by the idea that it is a formidable surgical 
procedure. It is far from this, and I have no reason for with- 
drawing my recommendation of it, which I gave in the firj-t 
edition of this book, published in 1873. 

The case in which Dr. Buck detached the auricle, is in brief 
as follows : 

The patient was a boy of nine years, in whose right auditory canal a playmate 
had thrown or pushed a bean. An effort was made to remove it by a physician, 
but it failed. The boy was then brought to Dr. Francis Delafield, of New York, 
who, with Dr. Buck — the little patient being under the influence of sulphuric 
ether — tried to dislodge the bean, which was seen between the anterior and pos- 
terior walls of the canal near the membrana tympani. These attempts were 
made with steel hooks. The bean was what is known as a locust bean, very hard, 
"the surface is essentially as hard as ivory" (Buck). A locust bean measures 
10 mm. in length, 7 mm. in breadth, and 5 mm. in thickness. After waiting for 
some days and making experiments with a dental drill, and by soaking the beans 
in hot water and nitric acid, and finding the results unsatisfactory, Dr. Buck 
determined to detach the auricle, which he did. The bleeding was profuse. 
The bean was seen lying transversely across the long axis of the canal, but it was 
so firmly impacted that there was great difficulty in removing it with the steel 
hook, although this was finally accomplished. The case finally did well, although 
the auricle healed slowly, and granulations formed in the auditory canal. A per- 
foration of the membrana tympani was found after the operation. This Dr. Buck 
is inclined to think was caused by the attempts at removal. A note from the 
physician who first saw the case just narrated, to Dr. Buck, 1 states that he never 
saw the foreign body at all, but that attempts were made to remove it by "a 
nurse or one of the lady guests at the house," who used a hair-pin, and then by 
" a gentleman guest," who used a crochet-needle. 

Thus the old story is repeated. Nowhere do "fools step in 
where angels fear to tread," more promptly, than when a foreign 
body has entered the auditory canal of some luckless child. This 
locust bean was probably firmly lodged by the hair-pin and 
crochet-needle of the "lady and gentleman guests" who took 
part in the hunt after a bean, which would have been easily re- 
moved by the syringe, if it had been left where it first lodged. 
This case caused Dr. Buck, who formerly looked somewhat 
askance at the syringe as the first means to be tried for remov- 
ing a foreign body from the ear, to state that "it is a fair infer- 
ence to draw from this case, that it is decidedly better for the 
general practitioner, when called upon to remove a foreign body 
from the ear, to restrict his efforts to the employment o( the 
syringe with tepid water." 



1 Medical Record, January, 1SS;>. 



192 FOREIGN BODIES. 

Dr. Lowenberg 1 reports an ingenious method by which he 
removed a small ivory ball, from the tip of a quill pen-holder, 
which had been forced into the ear of a boy nine years of age. 
Various attempts at removal, by other hands, wounded the 
canal, perforated the membrana tympani, and excited severe in- 
flammation. After the inflammation had subsided, Dr. Lowen- 
berg attempted to remove the body by syringing, by Valsalva's 
and Politzer's methods of inflating the ears ; but he failed. He 
then extracted the ball by bringing the point of a small brush. 
dipped in joiners' glue, in contact with its outer surface, allow- 
ing the glue to harden, and then extracting brush and ball to- 
gether. 

Dr. E. H. Clarke, who is quoted by Blake in the same report 
from which I have taken the description of Dr. Lowenberg's 
method, once adopted a similar procedure with success. The 
foreign body was a hard, smooth ball, and it was extracted by 
passing a thread through a small square of adhesive plaster, 
and bringing the latter, by means of a fine tube, into contact 
with the surface of the ball, when sunlight was concentrated 
upon it by means of a lens, until it softened and adhered, when 
it was easily extracted. These two methods are certainly to be 
commended as both ingenious and safe. 

Of the cases of foreign body in the ear, that I have seen in 
private practice, very few are worthy of more especial notice 
than I have already given them. 

In two of the cases, both male adults, the foreign bodies were 
thrown in the ear. In one case the patient was passing along 
the street when a bean was thrown into his ear. The bean was 
dislodged by means of a small hook, and then removed with an 
angular forceps. In the other case some young men were en- 
gaged in " flipping" beans, and one entered the auditory canal. 
It was displaced by a probe, and then removed by a syringe. In 
another case, an okra seed had been pushed through the mem- 
brana tympani in the efforts to remove it. Suppuration of the 
middle ear existed when I saw the child, and the okra seed 
could not be seen. In the course of a year it came out during 
the syringing, which was advised as a means of treating the 
ulceration. There was one case, in which a cockroach entered 
the ear of a man of thirty-six. He came to the office, stating 
that he had pain in the ear during the night, but without know- 
ing the cause. The insect was easily removed by the syringe. 
In another case, that of a lady, quite a large quantity of sand 

] Report on the Progress of Otology, by C. J. Blake, Transactions American Oto- 
logical Society, 1872. 



MARION SIMS ON FOREIGN BODIES. 193 

was removed from the canal and from the surface of the drum- 
head. Of the Manhattan Hospital cases, 76 in all, 65 were re- 
moved without an anaesthetic, and whether with another instru- 
ment than the syringe or not, at least without difficulty. Ten 
were removed under the use of sulphuric ether, and chloroform 
was used in one case. Failure to remove the foreign body did 
not occur in any case. Two of the cases are said to have been 
injured by instruments before they came to the hospital. If the 
notes had been fully kept, a greater number of cases of injury 
from attempts at removal would, I think, have been shown. 

In one of the cases the foreign body had been pushed into 
the tympanic cavity. It was removed, five days after the first 
visit to the hospital, by Dr. Pardee, he having dislodged it at the 
first visit. 

There were two cases in which no foreign body was in the 
ear, although one was supposed to be. In one case, a piece of 
the point of a lead-pencil broke off in the ear while the patient 
was carrying it in her hand. She ran against some obstruction 
and broke the pencil in her ear. It was easily removed with the 
syringe. 

My distinguished countryman, the late Dr. J. Marion Sims, 
published an article, illustrated by three cases, in the American 
Journal for Medical Sciences, 1 that very warmly and ably advo- 
cated the use of the syringe for the removal of foreign bodies 
from the ear, but which did not receive the attention it deserved. 

This was the first important article Dr. Sims ever published. 
So impressed was the literature of the period of Dr. Sims' writ- 
ing, with the idea that forceps, and so forth, must first be used 
before any other means are tried, that it was only by accident 
as it were, when washing away the blood caused by fruitless 
attempts to remove a foreign body by such instruments, that he 
found the syringe and warm water the very best means of re- 
moving such offenders. Dr. Sims gives Mr. Carpenter, of Castle 
Comer, Ireland, the credit for being the first to call the attention 
of the profession to the universal applicability of the syringe for 
the removal of foreign bodies from the ear. He also narrates 
the experience of no less a person than Sir Benjamin Brodie, 
who with characteristic British honesty, tells us how he failed to 
get a foreign body, a pea, from the ear, after using all sorts of 
methods, and finally left it to rot and come out of itself, or " to 
be washed out by a syringe." 

Dr. Sims maintained his interest in this subject long after he 
had won great fame as a gynaecologist. He read a paper upon 



1 Vol. ix., 1845, p. 886, 
13 



194 FOREIGN BODIES— CASES. 

"The Extraction of Foreign Bodies from the Ear" before the 
British Medical Association in 1878/ in which he repeated his 
views as to the value of the syringe. He criticised the ear syr- 
inges made in London as being clumsy, as having a large 
nozzle, so that they throw a large stream of water. Dr. Sims 
recommends for occasional use, in removing foreign bodies for 
example, the ear syringe so commonly sold in the United States. 
It is of hard rubber, and holds about an ounce. It is very light 
and is easily managed with one hand. Useful as this syringe 
is for occasional use, it is usually so carelessly made, and is so 
small, that the practitioner who has much use for an aural syr- 
inge will prefer one of metal, a size or two larger, but having 
the same nozzle, and made on the same general plan as the 
k * American hard rubber ear syringe." Ev en patients who are 
obliged to use a syringe for a long time, will find a metal syr- 
inge the cheapest. 

Dr. E. D. Speir, 2 of Boston, recommends pressure with the 
fingers "upon the skin, close to and in front of the tragus, car- 
ried upward and around the meatus, upon the auricle, and back 
again to their starting-point, when the manoeuvre is repeated 
several times," for the removal of a foreign body found in the 
cartilaginous portion of the canal, and lying upon the wall. 

The same movements of the canal, are advised to effect a 
change in position of a foreign body lying beyond the centre of 
the cartilaginous canal, or even one that has been pressed partly 
into the osseous portion. Dr. Speir gives several instances in 
which the position of foreign bodies in this canal has been 
changed by this procedure. It is especially recommended for 
foreign bodies that have not been tampered with by improper 
means. It is just these, that may be easily removed by a syr- 
inge. 

A Pea in the Ear for Thirty Years — Unpleasant and Painful Symptoms — Final 
Removal by the Patient Himself 

My friend, Professor William Darling, having told me of a 
well authenticated case of a foreign body remaining in the ear 
for thirty years, at my request, he procured the history for me. 
I regard it as of sufficient value to warrant its insertion in the 
patient's own words. 

When a boy in Scotland, nine or ten years old, I pnt a pea into my right 
ear, under the impression it would come out at my mouth. I was immedi- 

1 British Medical Journal, December, 1878, p. 868. 

2 American Journal of Otology, Vol. III. , p. 197. 



FOEEIGN BODIES — CASES. 195 

ately seized with excruciating pains, and the doctor was sent for. Of course, 
I told my father and mother where the great pain was located, but I neither 
told them nor the doctor the cause. I can remember them holding me in bed, 
while the doctor was dropping some liquid into my ear to try and relieve the pain. 
The doctor who attended me was the uncle of Professor William Darling, of 
New York, and I remember many expedients were tried to relieve my agony. 
Suppuration ensued, and after a time I got better, but the ear was a continual 
trouble ; if I got wet or cold it went to that sore ear. After coming to Montreal, 

I requested the late Dr. W. P. S to try and remove the pea, but he would 

not believe there was any foreign body in the ear, and it was only after urgent 
solicitations that he at last extracted what appeared to me to be the half of the 
outer skin of the pea, but which the doctor said was only "hardened wax." 
After any violent exertion I felt as if the pea was displaced, until I got a night's 
sleep. 

Before the opening of the Atlantic, now the Montreal and Portland railway, 
and before the road was ballasted, I rode from Sherbrooke to Montreal (100 
miles), with only an engine and tender, and the jolting on the rough road so 
displaced the pea, that at night it was impossible for me to sleep. I knew the 
pea was the trouble, so with as long a pin and as small a head as I could find, I 
determined to try and remove the pea which had now been in my ear over thirty 
years. After cautiously introducing the pin into the ear, a grating sound was 
felt, and with some trouble the pin head was got over the pea, and by slowly 
working the pin back and forward, gradually the pea was brought to the open- 
ing, when unfortunately the pin then slipped out. At this point, the narrator 
states, he awoke his wife, who in attempting to remove a " black thing " which 
she saw at the meatus, pushed it back. The patient, however, soon, by careful 
manipulation with the pin, removed the pea from the ear. 

The writer then continues: Half of the skin still adheres to the pea, but 
the division and germinating points are as plainly marked to-day as they were 
upward of fifty years ago. I am now sixty-one years of age. Previous to getting 
the pea out, I could never sleep on my right side, I was continually bothered by 
a most annoying singing when the pea was in. The hearing is unimpaired. 

Dr. Ludwig Mayer 1 has collected the cases of foreign bodies 
in the ear that he has been able to find in the literature of the 
fifty years preceding 1870. The whole number is 77. Of these 
persons 

16 were between 1 and 10 years of age. 
10 " " 10 " 20 " 

10 " " 20 " 50 " 

1 was over 50 " 

The age of the remainder is unstated. 

In QG cases the foreign body was in the auditory canal, 8 were 
in the cavity of the tympanum, and 3 in the Eustachian tube 
Of the three cases in the Eustachian tube, two were at the plia- 

1 Monatsschrift fur Ohrenheilkiiiule. Jahrgang IV., No. 1. 



196 FOEEIGN BODIES— CASES. 

ryngeal orifice. In the third case, a barley-corn projected from 
the pharyngeal orifice, and at the post-mortem section — it is not 
stated of what disease the patient died— the foreign body was 
found to reach into the osseous tube. 

In two of the cases the foreign body was in the ear but twelve 
hours before seen by the surgeon who reported them. In only 
12 of the cases was the foreign body in but a short time, vary- 
ing from days to weeks. In the remainder they were in for 
years. Four were in for four years, two for twenty years, one 
for forty-five, and one for more than sixty years. 

The substances found were— a needle, carob beans (6), beans 
(3), cherry pits (6), living larvae (4), peas (1), a wisdom tooth of 
the upper jaw, a grain of coffee, a snail, pearls (2), point of a 
glass syringe, a glass ball, wads of cotton (6), a carious tooth, a 
piece of hard coal, a wad of paper, a gun cap, a piece of bone, 
a piece of bread, a bit of lead, laminaria bougies in the tube (2), 
a millet seed, a piece of coral, a barley-corn in the tube, and an 
agate stone. 

Dr. Mayer finds, on an analysis of these cases, that the at- 
tempts to remove the foreign bodies had usually caused much 
more trouble in the ear than their presence. 

In 48 of the 77 cases, functional and pathological changes are 
said to have occurred as a result of the presence of the foreign 
bodies. In 11 of the cases it is reported that the attempt at re- 
moval caused these disturbances. 

Pain in the ear was generally the disturbing symptom in 
those cases in which the foreign body caused any trouble. This 
was chiefly due to the irritation of the lining membrane of the 
canal, which is so closely allied to periosteum in its nature as to 
be subject to intense pain. Besides, as shown by F. E. Weber, 
the pain in the cartilaginous portion of the canal is severe on 
account of the fact, that the fibrous tissue of the cartilaginous 
canal is fastened to the squamous portion of the temporal bone, 
above and behind, by tense fibres. As has been shown, the 
canal is very richly supplied with nerves, and this serves to ex- 
plain the severe pain experienced when a rough body is in the 
ear, or when the canal is abraded by attempts at the removal 
of a smooth and harmless one. 

Polypi arose five times in consequence of the inflammation 
of the ear. Severe hemorrhage occurred five times, and always 
in consequence of attempts to remove the foreign bodies. 

In one case there was delirium, and in three cases suppura- 
tive meningitis, and once a cerebral abscess, with, of course, a 
fatal result. 

The membrana tympani was perforated, and the cavity of 



FOREIGN BODIES — CASES. 197 

the tympanum inflamed, from the efforts at extraction in the 
three cases in which meningitis resulted. 

In one case the patient, a child, attempted to push the for- 
eign body — a piece of flint-stone — out through the other ear. 
Suppurative meningitis occurred, and death resulted in a few 
days. The stone was so firmly fixed in the mastoid cells that 
trouble was experienced in removing it, even at the post-mortem 
examination. 

In one case on the section, a wad of paper was found in a 
cerebral abscess which communicated with a collection of pus 
in the tympanic cavity. It had probably been forced there by 
the attempts to remove it. 

The disturbances of the nervous system were considerable in 
some cases, and they throw light upon the influence of chronic 
aural suppuration upon this part of the organism. In three 
cases there were general convulsions ; there was paralysis of 
one side of the face in five cases, atrophy of the arm in two 
cases, twice there was anaesthesia of the whole of one side of 
the body. There were two cases of epilepsy. The facial paraly- 
sis was caused by a continuation of the inflammation to the 
Fallopian canal and the facial nerve. 

The convulsions and the epilepsy were probably caused by 
reflex action through the medulla oblongata, due to peripheric 
irritation of the fifth pair of nerves. 

The cases of atrophy of the arm and anaesthesia of the body 
are so imperfectly reported, that Mayer does not attempt any 
explanation of them. 

Our limits do not allow of a complete transcription of the 
cases which Dr. Mayer has collected with such care ; only a few 
of the more curious or important ones can receive a further 
allusion. 

In one case, a horse coughed some oats into the ear of a man 
as he was going by the animal. 

Deleau, Junior, removed a foreign body from the cavity of 
the tympanum, an agate stone, by an injection of water through 
the Eustachian tube. The reader will find this case fully re- 
ported in Lincke's collection of " Monographs on the Ear." l 

The case of atrophy of one arm, epilepsy, anaesthesia of 
one-half of the body, is the famous one of Fabricius Hildanus, 
quoted by Von Troltsch. 2 The patient, a young woman of eigh- 
teen years, is said to have been cured of all these symptoms by 
the removal of the foreign body, a glass ball, eight years after ir 



1 Lincke's Sannnlung\ Bd. T., p. 154. 

• Text-book, American translation, p. 400. 



198 FOREIGN BODIES — CASES. 

was inserted. (See latter part of this chapter for a full account 
of this case.) 

Handfield Jones ' saw a case in which hemiplegia with con- 
vulsions arose from the presence of insects in the ear. 

Wederstrandt 2 reports a case in which molten lead was 
poured into the right ear of a drunken man. The pain was not 
severe ; the hearing power was gone. The patient was able to 
leave the hospital in eight days. The lead was not removed, 
and severe suppuration occurred. Seventeen months after he 
was in the same condition, with paralysis of the right orbicu- 
laris palpebrarum muscle ; a polypus had grown over the lead. 

In three of the cases death occurred, and in all of them it 
may properly be said to have been caused by attempts to re- 
move foreign bodies, which, whatever disturbances of the sys- 
tem they might have produced, would not probably have led to 
death. 

Mr. Pilcher, in his work on the ear, 3 reports a very instructive 
case from the Lancet, in which surgeons of a London hospital 
attempted to remove from the ear of a child of seven years of 
age, the head of a nail, which they never saw, but which they 
felt with a probe. 

The first surgeon to whom the child was brought said he saw 
the head of the nail, but he did not attempt to remove it because 
four men could not hold the boy's head still. A director, dress- 
ing forceps, which were both bent in the forcible efforts, forceps 
with hooks were used, and they were also bent straight, but the 
nail could not be removed. An incision was then made behind 
the auricle, and the meatus was exposed. A search was then 
made for the nail, with forceps and an elevator. Tooth forceps 
were then used; three pieces of metal, which appeared to be 
pieces of the nail, were removed by these delicate instruments. 
The malleus bone was then removed by the forceps. 

The patient was now so exhausted that "his pulse could 
scarcely be felt, and his skin was bedewed with cold perspira- 
tion." 

The operator then stated that he had used "more force than 
was warrantable." He thought, however, there was now a large 
opening (sic) through which pus might escape, and yet he feared 
that a portion of the petrous bone might exfoliate, and that 
meningitis and abscess of the brain might occur. He stated 

1 Sydenham Society Year-book, 1861. 

2 American Journal of the Medical Sciences, Vol. IX. 

3 Treatise on the Ear, American edition, by George Pilcher. Philadelphia, 1843. 
Reprint, p. 219. 



FOREIGN BODIES CASES. 199 

that he had seen three or four cases which had terminated in 
this manner. Of course the little victim died, and that too on 
the third day after these operative attempts. 

The post-mortem examination revealed softening of the base 
of the brain, and of the anterior part of the hemispheres. Not a 
vestige of the bony part of the external auditory canal remained, 
it having been removed during the operation, and the floor of the 
tympanum was also wanting. There was considerable pus in 
the tympanic cavity. 

"The nail not being in the tympanum, sections were made 
through the cochlea, vestibule, semicircular canals, and mastoid 
cells; but there was no nail to be found." 

The following case, also belongs in this sad category of great 
damage done by unwise attempts to extract a foreign body. ' 

Extraction of a Foreign Body from the Tympanum, with Resection of the Tym- 
panic Ring. — The following case is related in the Norsk Magazin for Laeger- 
idenskaben, vol. xii., No. 11. A little girl, aged four, while playing on the sea- 
shore had a stone pushed into her ear by her sister. A few days later, upon the 
sister's confessing her trick, the mother attempted to dislodge the stone by 
means of a hair-pin, but not succeeding, she took the child to several physicians, 
one after the other, all of whom made repeated unsuccessful attempts to extract 
the foreign body. It was then, two and a half weeks after the accident, that the 
child was sent to the Eigshospital in the service of Dr. J. Nicolaysen. Examina- 
tion showed numerous erosions in the external auditory canal, the outer two- 
thirds of which was swollen and ecchymotic, the inner third entirely denuded of 
skin and periosteum. The drum-head was gone, the tympanic ring bare, and the 
cavity of the tympanum filled up by the foreign body. The stone seemed to be 
wedged tightly in the anterior part of the cavity. There was some purulent 
secretion from the tympanum and meatus. The first efforts at extraction were 
unsuccessful, and the operation was put off till the following day to give time 
for the manufacture of some strong hooks. When these were procured they 
Avere slipped past the stone, but were broken off and their points left in the 
cavity of the ear. As the child had several times stopped breathing the chloro- 
form was withheld and the operation again interrupted. The third attempt was 
successful. A very fine saw was introduced and two notches made in the tym- 
panic ring, one directly forward and the other downward. Then the intervening 
section of bone, about one-fourth of an inch in length, was knocked off with a 
chisel. The stone was now readily extracted and with it the broken hooks and 
ossicles. The stone measured 8.75 mm. in length, 5.5 mm. in width, and 4:. 75 
mm. in thickness. The well-meant efforts at extraction had succeeded only in 
wedging it in the tympanic orifice by its largest diameter, thereby destroying 
the drum-head and the ossicles. 

The fact has already boon alluded to in this chapter, that 
persons sometimes suppose there is a foreign body in the ear, 

1 Medical Record, vol. \\\\. p. "JOS. 



200 FOREIGN BODIES — DELUSIONS. 

when there is actually none in it, and when there probably never 
has been one there. At times delusions occur on this subject. I 
have seen several cases of the kind which are quite remarkable. 

Two cases I saw at the New York Eye and Ear Infirmary, 
where the patients, who were women of the lower class of life, 
supposed that pins were in the auditory canal. No amount of 
reasoning, nor the subterfuge of pretending to remove a pin from 
the ear, by syringing, could satisfy these females. 

In another case a woman brought her son to my clinic in the 
University of New York, and stated that he was passing pieces 
of anthracite coal from the external meatus. She had quite a 
quantity of coal in a handkerchief, which she said had been 
passed from the ear. Some of these pieces of coal were larger 
than the auricle. The boy agreed with his mother in her insane 
statements. I am sorry that they passed from my observation 
before I could fully investigate the cause or motive for the 
delusion. 

In another part of this work ' allusion will be again made to 
the cases, not uncommon, in which patients with chronic disease 
of the middle ear, and persons who perhaps were of sound mind, 
firmly believed, in spite of the negative result of my examina- 
tions, that there was inspissated cerumen in the auditory canal. 
Indeed, the sensation of fulness of the canal in chronic cases of 
disease of the middle ear, is often so decided as to render such a 
belief pardonable, in a person who has not full confidence in the 
surgeon who examines the ear. 

It has been mentioned, in the second chapter, that the hairs 
of the auditory canal sometimes lie on the drum-head, and thus 
become irritating foreign bodies. 

I quite often see cases where the disk of Toynbee's artificial 
membrana tympani has become detached from the wire, and 
remains at the bottom of the canal. By first displacing it from 
its position with a probe, the disk may be readily removed with 
the syringe or forceps. If these cases did not occur in adults, 
who are accustomed to the presence of a foreign body in the ear, 
we should see the same unreasonable fright at the presence of 
this piece of rubber, as we do in cases of no more importance. 

We see from all this, that it is by gentle manipulations, made 
with delicate instruments, under the guidance of personal skill 
and ingenuity, that these cases are to be managed. An eminent 
artist was once very earnestly inquired of by an amateur, as to 
what he mixed his colors with. His answer was, " With brains, 



Chapter on Chronic Xon-suppurative Inflammation. 



FOREIGN BODIES. 201 

sir ! " Perhaps nowhere in surgery, does this old anecdote better 
illustrate the necessity of using instruments with brains, than in 
the removal of foreign bodies from the ear. 

The conclusions to which I have come, as to the mode of a 
procedure in cases of suspected foreign bodies in the ear, may 
be formulated as follows : 

1 . Assure one's self by ocular examination of the presence of 
the foreign body. 

2. Try syringing with a large syringe with a small nozzle, the 
patient being placed in various positions, according to the situa- 
tion of the body. 

3. If this fail, use a Daviels' spoon, a wire loop, a bent probe, 
a cystotome used by oculists, or the like, and attempt to change 
the position of the foreign body, so that the stream of water can 
get behind it and force it out. This displacement should gen- 
erally be done under ether, especially in the case of children 
who have been frightened by previous attempts at removal. 

4. If the foreign body be so wedged in that this method fails, 
Lowenberg's glueing procedure, Elsberg's instrument, or some 
one of the numerous aural forceps, are worthy of use. 

5. If no urgent symptoms occur, and these attempts at removal 
have caused excoriation and inflammation of the auditory canal, 
wait until they have subsided, meanwhile syringing the ear with 
warm water several times a day. 

6. If all ordinary and safe procedures through the meatus 
have failed, separate the auricle and get at the foreign body 
from behind. 

7. In a case when there are no symptoms of injurious effects 
from the presence of a foreign body, do not act, as if it were 
one in which the substance should be removed at once, and at all 
hazards. 

FOREIGN BODIES IN THE EUSTACHIAN TUBE. 

Among the cases whose statistics are reported by Dr. Mayer, 
two will be noticed where laminaria bougies were broken off in 
the Eustachian tube. Dr. Hecksher, of Hamburg, relates an 
interesting case that belongs to this class. The patient was a 
principal of a college, who had been accustomed to treat his 
own ears — which were affected with chronic catarrh — by the 
use of the Eustachian catheter. 

Dr. Hecksher received a telegram one day from the patient. 
for whom he had occasionally prescribed, stating that he had 
got a foreign body in one of his Eustachian tubes. When Dr. 
Hecksher reached the patient, he gave the following history : 



202 FOREIGN BODIES— EAR-COUGII. 

He had introduced through a metallic catheter a whalebone 
probe into the tube. On the end of this probe was fastened with 
a silk thread a raven's feather, which he used for the purpose 
of washing away mucus from the tube. 

One evening as he was using the apparatus, he drew back 
the probe without the feather, and he found that he had left it 
in the tube. It caused so much pain that he could not sleep. 
Attempts were made by a physician to remove the foreign body, 
but they failed. Dr. Hecksher then attempted to remove the 
body, but the parts were so swollen that he could not practise 
rhinoscopy, and see the feather, and he failed with various 
kinds of forceps to remove it. 

So much inflammation ensued that he was obliged to desist, 
and use antiphlogistic treatment ; but the patient finally re- 
moved the feather himself by the aid of the catheter introduced 
in the usual way, and his finger passed behind the uvula. 

Politzer ' also relates two cases, quoted from Urbantschitsch 
and Schalle, where foreign bodies have reached the cavity of 
the tympanum from the pharynx. The first was an oat husk, 
which had stuck in the throat in chewing an ear of grain. It 
entered the Eustachian tube and the tympanic cavity, and came 
through the external meatus. 

In Schalle's case a piece of hard rubber syringe, employed in 
douching the nose, broke off, and entered the tube and tym- 
panum. In the drum cavity it caused acute suppuration, and 
was removed by incision of the membrane. 

EAR-COUGH. 

Every practitioner who has been at all in the habit of exam- 
ining ears, must have observed a cough which occurs in many 
patients, whenever a certain part of the auditory canal is touched 
by a cotton-holder, a probe, or the like. There is the greatest 
variation in the sensitiveness of patients in this regard. Some 
of them scarcely tolerate any contact with the osseous canal 
without responding by a cough, while others, and by far the 
greater number, during a long course of treatment never ex- 
hibit any disposition to cough, when the canal is touched. 

Certain other reflex symptoms from irritation of the walls 
of the canal have been observed for centuries. Such are sneez- 
ing and vomiting, and even epileptic seizures. For example, 
Troltsch 2 quotes from Pechlin, who, writing in 1691, says he 

1 Text-book, English translation, p. 631. 

2 Lehrbuch, Sechste Auflage, p. 522. 



EAR-COUGH. 203 

knew a man in whom contact with the external auditory canal 
always caused vomiting. Arnold, 1 also quoted by Troltsch, tells 
a story of a now famous girl, who suffered for a long time from 
a severe cough and expectoration, who besides often vomited 
and gradually became very thin, and who was finally relieved 
from all her symptoms by the removal of a bean from each ear. 
Arnold relates another case where a " disease of the chest " was 
cured by the removal of a foreign body from the ear. Toynbee 2 
also records the case of a patient, who suffered from a cough 
which no treatment subdued, until a portion of dead bone was 
removed from the auditory canal. The most important of all 
the cases of reflex symptoms from irritation of the external 
canal of the ear yet reported, is that of Fabricius, of Hilden, 
whose case Troltsch also quotes. A girl of ten years of age put 
a small glass ball in her ear. Many attempts were made to re- 
move it, but they were unsuccessful. Finally she was seized 
with hemicrania, anaesthesia of the entire left side of the body, 
alternating with severe pain, until at last epileptic attacks oc- 
curred, with atrophy of the left arm. At eighteen years of age 
she came under the care of Fabricius, who drew out the story 
of the glass bead, which had been well-nigh overlooked, since 
she never complained of earache. He removed the foreign body 
and cured the patient of all her troubles, as he writes to his 
friend Bauhinus, " Restituum est quoque brachium." 

Schwartze and Koeppe 3 also speak of reflex phenomena from 
foreign bodies in the canal. Koeppe, 4 in an article upon "Re- 
flex Psychosis from Aural Diseases," relates two cases where 
treatment of the nose, throat, and ears restored the patients to 
sound mental condition. In the first case there was ozaena and 
catarrh of the ears ; in the second hardened blood was removed 
from the auditory canal, where it had remained for years, as 
the result of a hemorrhage from a fall, or several falls, upon the 
head. These cases are exceedingly interesting. 

Dr. Kupper 5 reports a case of epilepsy from a foreign body 
in the auditory canal, and also a case of cerebral irritation from 
inspissated cerumen., 

A young woman of eighteen was admitted to the hospital with the following 
history: She had had severe pain in the right ear, and suppuration had finally 
occurred. Toothache also set in later, when she put a piece of a root in the 



1 Loc. 


cit. 
















2 Treatise on the 


Eai 


r, English 


edition. 


P 


89. 


3 Archiv fiir Ohrenh 


eilkunde, 


Bd. 


v., 


s. 


28;?. 


4 Ibid. 


, Bd. 


IX., 


p. 220. 










5 Ibid. 


, Bd, 


XX 


i P- 


107. 











204 EPILEPSY FEOM FOREIGN BODY. 

suppurating ear to relieve the pain. She was not able to remove it, and since 
that time she had suffered from epileptic seizures. They often occurred daily 
and sometimes several times a day. An examination showed the young woman 
to be well except as to the right ear. The tuning-fork was heard better on that 
side, the watch was only heard when laid upon the ear. The auditory canal was 
sensitive on pressure, and full of pus. Careful syringing caused vomiting and 
vertigo. The canal was filled with polyjDi that were very sensitive. The pa- 
tient was put under the influence of chloroform, and the polypi were removed. 
On the next day the foreign body was removed with a blunt hook and syring- 
ing, the patient being again under the influence of chloroform. The piece of 
wood was 1 cm. long and -J- cm. thick. Only two attacks of epilepsy occurred 
after the operations, one within a few hours of the last operation, the other two 
days after. The patient also recovered full hearing power. 

The second patient was a woman of seventy-six, who suddenly began to have 
cerebral symptoms, headache, vertigo, vomiting, severe spasm of the muscles of 
the face and of the extremities. She especially complained of pain in the right 
ear, and it was found to be sensitive on contact. The organs of the old lady 
were found to be in good condition, except the right auditory canal, which was 
completely stopped by wax. The mass was removed with great difficulty in 
about two days, after softening it. The necessary manipulations caused serious 
symptoms, but as soon as the wax was loosened they disappeared. The mem- 
brana tympani was found to be the seat of old disease, and was adherent to 
the promontory. There was no hearing-power on that side. In six weeks the 
patient, who was much run down by her symptoms, had fully recovered and was 
able to go out. 

Wilde 1 also, quotes from Br. Maclagan "a case of epilepsy 
and deafness, dependent on the presence of a foreign body in 
the ear." After the seed of a sycamore, which had been in the 
ear ten years, was removed, the epileptic attacks ceased, and 
the deafness declined. Sir William seems to have been some- 
what skeptical about this case, and he says: "I must confess 
that I am inclined to bring in the Scotch verdict of 'non 
proven,' as far as the seed is concerned. The state of the ear, 
either before or after the removal of the foreign body, has not 
been recorded ; nor whether the seed ruptured the membrana 
tympani, or caused any disorganization of the parts.*' Wilde 
goes on to say, that if the introduction of a foreign body into 
the canal causes epilepsy, it must be by pressing upon the sen- 
sitive part which he had met in some persons, in syringing the 
ear. He was not able to explain the phenomenon, but later on 
in his book he quotes another writer, 2 who explains it by hyper- 
esthesia of the auricular branch of the pneumogastric. Strange 
to say, there remains a doubt, from the varying statements of 
anatomists, as to whether the auditory canal is or is not sup- 

1 Aural Surgery, p. 189. 
2 Loc. cit., p. 326. 



BRANCH OF PNEUMOGASTRIC IN EAR. 205 

plied by the pneumogastric. Quain 2 only speaks of the auricu- 
lar branch of the pneumogastric as supplying "the integument 
of the back of the ear." 

Sappey 2 describes it as supplying the canal, as do other au- 
thors, for example, Gruber, 3 who says : " The auricular branch 
of the vagus extends not only to the posterior surface of the 
auricle, but also to the cartilaginous part of the auditory canal. 

Troltsch 4 also describes an auricular branch of the vagus 
which, as he says, enters the posterior part of the osseous canal. 
This acceptance of Arnold's discovery of the auditory branch of 
the pneumogastric is usually accepted, although the most com- 
plete article on ear-cough of which I know, that by Cornelius 
B. Fox, 5 agrees with Quain, that the auricular branch of the 
pneumogastric only supplies the posterior part of the pinna (au- 
ricle). In about twenty per cent, of the persons examined by Dr. 
Fox there was found a hypersesthetic state of the nerve supply- 
ing the auditory canal, that is, they were persons in whom any 
slight titillation of the nerve produced a sense of tickling in the 
throat. These are the persons alluded to in the opening sen- 
tences on this subject in this book. Dr. Fox also believes, that 
when this condition exists, it is a congenital peculiarity, and that 
the connection between the nerves involved takes place in the 
brain. The cases of ear-cough cited by Fox are similar, and in 
some instances identica], with those I have enumerated. There 
is no attempt made to trace cough to evanescent or temporary 
influences, such as cold upon the face and auditory canal. In 
the two cases of his own cited by Fox, in the one instance the 
cough was caused by wax and an ulcer of the canal ; in the 
other, by an inflammation of the canal produced by the use of a 
spirituous irritant. Lockart Clarke 6 supports Fox's view as to 
the origin of ear-cough, "in the fibres of the fifth cerebral nerve 
distributed to the auditory canal." Mr. John Wood, 7 an examiner 
in anatomy of the University of London, states positively that he 
has traced a branch of the vagus into the auditory canal, "pass- 
ing through a minute foramen between the jugular fossa and 
the glenoid." 

1 Elements of Anatomy, eighth edition, p. 500. 

2 Traite dAnatomie, Tome III, p. 842. 1877. ''La peau du conduit externa est 
extremement sensible. . . . soit enfin an rameau aurioulaire do pneumogastrique, 
qui vient se perdre dans la peau de la portion osseuse du conduit." 

3 Lehrbucb, p. 144. 

4 Ibid., VI. Aufgabo, p. 29. 

5 British Medical Journal, December 18, 1869, p. 650. 

6 Ibid., 1870, p. 51. 
1 Loc. cit., p. 328. 



206 WOAKES ON EAR-COUGH. 

From the facts so well established since the time of Fabricius, 
theoretical writers have made the most possible. Woakes 1 seems 
hardly to consider them exceptional,, and argues with ingenuity, 
but I cannot think soundly, that there may be quite a large class 
of cases of affections of the larynx, that are due to auditory irri- 
tation. He suggests spasmodic croup as occasionally owing its 
origin to a draught of cold air falling upon the ear. He also 
attempts to explain "derangement in the iunervation of the 
laryngeal muscles*' as possibly due to reflex influence from the 
auditory branch of the vagus. He instances the coachman ex- 
posed to east wind and rain, and who finds his voice "husky, 
shrill, or faltering*' in the evening, and he argues that the excit- 
ing causes are draughts of cold air and wet upon the surface 
"the impression of which, is conveyed by the afferent vaso-motor 
nerves associated with the cerebro-spinal nerves of the surface 
receiving the chill, to the sympathetic ganglion with which they 
communicate : in this instance, the superior cervical ganglion." 
Dr. Woakes traces the irritation, 1, from the vaso-motor fibres 
associated with the auricular branch of the pneumogastric ; 2, to 
the secondary vaso-motor centre, the ganglion of the pneumogas- 
tric, whence he says it is deflected through a sympathetic fasci- 
culus to the first cervical ganglion ; 3, thence by the nervi molles 
to the vessels distributed to the mucous membrane of the larynx. 
He rejects the simple idea that the morbid impression is con- 
ducted along the sensitive fibres, from one region to another. 

Orne Green 2 suggests in a review of Dr. Woakes' book quoted 
by Woakes himself, that the mechanical commotion of the larynx 
caused by the cough, is the cause of the local inflammatory mis- 
chief in this organ. The subject is an interesting one, but the 
cases of reflex phenomena from irritation of the canal are too 
infrequent, in my opinion, to justify the deductions of Woakes in 
regard to laryngeal paresis, and subsequent inflammation. Dr. 
Woakes quotes an amusing story, from Miss Edgeworth's tales, 
which will bear repetition : This author relates that a choking 
Norwegian clergyman at a feast, was relieved by a blast of air 
from a bellows, which a friendly companion blew into his ear. 
" The effect was magical : the expulsive action of the laryngeal 
muscles, called into play by this novel method, speedily got rid 
of the food which the gluttonous haste of the pastor, had caused 
to go the wrong way." 

Woakes 3 points out that sneezing caused by irritation of the 



1 Deafness, Giddiness, and Noises in the Head, p. 74 et seq. 
' 2 Boston Medical and Surgical Journal, 1879, p, 911. 
3 Loc. cit., p. 93. 



EAK-COUGH. 207 

auditory canal, cannot be due to or explained by referring it to 
"an irritation of the third branch of the fifth nerve exciting the 
motor laryngeal branches of the vagus, through communications 
existing between the roots of these nerves," as claimed by Fox, 
Clarke, and Russell, because with the act of sneezing, the vagus, 
as a motor nerve, can have nothing to do. 

These cases are, I believe, rare and exceptional, and I am 
not ready to accept Dr. Woakes' theories of laryngeal paresis 
and cough, or to believe that we have any but very infrequent 
occasion, to refer to the auditory canal for the explanation of 
coughs. When this theory was first promulgated in this coun- 
try, I was called to see a child of six months of age, who suf- 
fered from persistent cough. I was asked to examine the ear 
to explain the trouble. But while the history showed that the 
child had recently had pleuro-pneumonia, the ears revealed 
nothing abnormal. The cough in this case may easily have been 
due to pleural adhesions. I only mention the case, to show how 
ready we all are to give up obvious and simple explanations, to 
search for those that are recondite. 

Ear-cough is a very uncommon disease ; when it does occur, 
we may usually find an obvious local cause for it in the audi- 
tory canal, as in the classical cases, such as a foreign body 
or inspissated cerumen. To trace any considerable number of 
laryngeal affections to transient impressions on the auditory 
canal, to impressions that act more directly upon other parts 
of the surface of the body, is to go beyond the bounds of what 
seems to me logical reasoning. To produce ear-cough, we must 
have a continuously acting irritant. I do not deny that a blast 
of air upon an auditory canal, in cases such as make up the 
twenty per cent, contingent of Dr. Fox's tables, may produce 
ear-cough, but withdraw the draught, and the cough will cease, 
just as it does when the bean, or wax, or probe is removed from 
the ear. It seems to me, very unlikely that a permanent lesion 
is produced by such a temporary influence. 



THE MIDDLE EAR. 



CHAPTEE IX. 

ANATOMY OF THE MIDDLE EAE. 

Statistics of Diseases of tlie Middle Ear. — Membrana Tympani. — Shrapnell's Mem- 
brane. — Eivinian Foramen. — Light Spot. — Layers. — Blood-Vessels. — Nerves. — 
Lymphatics — Cavity of the Tympanum. — Scheme for Studying Boundaries of this 
Cavity. — Ossicula Auditus. — Blood- Vessels. — Nerves — Mastoid Process. — Eusta- 
chian Tube, Historical Account of. — Physiology of the Middle Ear. 

By far the greater number of aural diseases affect what is 
known as the middle ear. Of 4800 cases, occurring in my pri- 
vate practice, 3673 were diseases that involved these parts 
chiefly. 

Biirkner, in his statistical tables, already quoted, in a total 
number of 58,645 cases, places 39,238 in the category of diseases 
of the middle ear. This makes a percentage of nearly 70. My 
own statistics exhibit a percentage of more than 70. Those of 
the Manhattan Eye and Ear Hospital for thirteen years, more 
than 76 in a hundred. Of a total of 10,335 cases, 7957 were af- 
fections of the middle ear, It is probable that a more exact 
knowledge will in the future diminish this proportion somewhat. 
I believe that it will yet be found, that diseases of the labyrinth 
and of the trunk of the acoustic nerve, are more frequent than 
is now supposed. However this may be, the diseases of the 
middle ear, will probably always far exceed in number those 
of the other parts of the organ. The anatomy of this region, 
therefore, demands a careful and exact study. 

By the term middle ear, we mean the membrana tympani. 
the cavity of the tympanum, the mastoid cells, and the Eusta- 
chian tube. 

THE MEMBRANA TYMPANI. 

The membrana tympani, or drum-head, forms the boundary 
between the external and middle oar. It partakes of the char- 
acteristics of these two parts, in being composed of integument 
and mucous membrane, while it has one structure — the middle 
or fibrous layer— that is peculiar to itself. 



212 



MEMBRANA TYMPANI. 



The upper border of this membrane lies 7 mm. nearer to the 
entrance of the external auditory canal than the lower. The 
posterior border is about 5 mm. nearer this entrance, or mea- 
tus, than the anterior. The angle that the membrana tympani 




Fig. 52. — The Right Temporal Bone, without the Petrous Portion, in connection with 
the Ossicula Auditus of a Newly-born Child, seen from within (after Riidinger). 1 4, Is above 
the incus, whose short process is directed nearly horizontally backward ; 5, the long arm of 
the incus, which extends freely into the cavity of the tympanum ; 6, the malleus, in articu- 
lation with the incus ; 7, long process of the malleus, which runs under the crista tympanica, 
in a furrow, to the fissura petroso-tympanica ; 8, the stapes, in articulation with the incus. 

makes with the axis of the auditory canal, is one of about 55°. 
The inclination of the two membranes to an angle opening up- 
ward is one varying from 130° to 135°. In the newly born it was 
formerly supposed, that the membrana tympani lies more hori- 




Fig. 53. — Left Temporal Bone of the same Subject as preceding Figure. 

zontally than in the adult, and that it is almost in the same line 
with the upper wall of the external auditory canal. 

According to Pollak, quoted by Politzer, 2 this is incorrect. 



1 Atlas des Mensclilichen Gehororganes. 

2 Text-book, translation, p. 20. 



Munchen, 1867. 



MEMBKANA TYMPANI. 



213 



Pollak has made numerous measurements, and he states that 
there is no perceptible difference between the inclination of the 
membrane of the newly born and that of the adult. 

The peculiar manner in which the membrana tympani is 
placed in the canal, causes it to form an acute angle with the 
lower and anterior wall of the auditory canal, but an obtuse one 
with the upper and posterior wall. 

The general shape of the membrane is elliptical ; but the 




Fig. 54. — Section through Tympanic Cavity, Left Side (actual size, anterior half). 1, 
Squamous portion of temporal bone; 2, mastoid cells; 3, membrana tympani; A, A. 
chorda tympani ; 5, aqueductus Fallopii ; 6, incus (body) ; 7, malleus (handle) ; S, Eusta- 
chian tube ; 9, fossa? (middle cerebral) ; 10, groove for meningeal artery. 



regularity of the ellipse is broken in upon by the incomplete- 
ness of the bony ring surrounding the membrane. In the upper 
part of this bony ring an oval section is wanting ; this space is 
known as the segment of Rivini. 

The long axis of this ellipsoid runs downward and forward. 
the shorter backward and downward. If the diameters of the 
membrane are measured in the direction of the axis of the ellip- 
soid, that of the long axis is 0.5-10 mm., and the horizontal is 



214 shrapnell' s membrane. 

8 mm. Measured in the usual manner, the horizontal diameter 
is 8-8.5 mm., and the vertical 8.5-9 mm. 

The Rivinian segment is filled by the tissue of the cutis and 
the mucous membrane of the tympanic cavity. The greater 
part of the fibres of the tendinous ring of the membrana tym- 
pani bend from their former course, and at this point turn 
toward the short process of the malleus, which lies more deeply 
where it is inserted. The remainder of the tendinous fibres of 
the ring pass upward, and are lost in the connective tissue of 
the periosteum. 

This causes an irregular triangular space to be formed, 
bounded above by the Rivinian segment, and on each side by 
two bands, which attach the apex of the small process of the 
malleus, to the anterior and posterior corners of the osseous 
groove. 

■ This space, and the tissue filling it, was first described by 
Mr. Henry Jones Shrapnell, 1 and named by him the membrana 
flaccida. It is often called Shrapnel] *s membrane. Mr. Shrap- 
nell considered that the function of this flaccid membrane was 
to protect the more tense fibres during the effects of sudden and 
loud sounds, or the actions of coughing and sneezing, when by 
yielding it saves the tense fibres from being ruptured. In the 
hare and the sheep, that would be otherwise defenceless animals, 
were it not for the great power of their ears to warn them of 
approaching dangers, this structure is remarkably developed. 

The tissue composing Shrapnell's membrane is less tense than 
the remainder of the membrana tympani, and sometimes falls in 
like a pouch toward the tympanic cavity. It consists of a very 
thin layer of cutis and of mucous membrane. The mucous 
membrane extends to the osseous edge of the Rivinian segment, 
and from here passes over to the projecting neck of the malleus 
bone, which lies opposite. 

The existence of a minute opening in the membrane — the so- 
called Rivinian foramen — has been warmly disputed from the 
time of its discovery, 171?, by Rivinus, 2 a professor in Leipsic, 
until the present day. Professor Patruban, 3 of Vienna, found 
such an opening in 300 membranes, part of which were healthy, 
part diseased. He allowed a fine stream of quicksilver to pass 



1 London Medical Gazette, vol. 10, p. 120. Several German authors speak of Shrap- 
nell as Odo Shrapnell; hut his name, as it appears in the original of his articles, is as 
here given. 

- According to Von Troltsch, the so-called foramen of Ririnus was first discovered 
"by Glaser, in 1680, who was then professor in Basle. Bochdalek, however, claims the 
discovery for Colle. 

3 Monatsschrift fur Ohrenheilkunde, Jahrerans: III., No. 1. 



RIVINIAN FORAMEN". 215 

into the so-called canal, and it always appeared on the other side 
of the membrana flaccida. 

Professor Joseph Gruber 1 has also found the foramen in many 
specimens. Inasmuch as he oftener found it in pathological 
specimens, he thinks that its size is at least increased by disease. 
Gruber does not believe that it is an opening always to be found ; 
but that it is one frequently observed, and that it would be an 
interesting inquiry as to how far it is the result of disease. 

Politzer 2 thinks that the Rivinian foramen is a constant ap- 
pearance, not an anomaly or result of disease. 

Hyrtl 3 denies the existence of the foramen, and says that 
he has never found it, either on the adult or infantile cadaver. 
The ability to blow tobacco-smoke from the ears is the result, he 
thinks, of a want of development in the upper part of the mem- 
brane. 

Professor Bochdalek, of Prague, rediscovered the opening at 
the upper margin of the membrana tympani, one-third to three- 
fourths of a line from the edge, and reopened the discussion 
which Hyrtl seemed to have closed. 

If the Rivinian foramen, or canal, does exist in the membrana 
flaccida, it is so small that only a fine bristle, or hair, will pass 
in it, and the anatomist must sometimes persevere for hours with 
a magnifying-glass, in order to find it. Bochdalek 4 describes his 
discovery of the opening as follows : "To my great astonishment 
I saw, by means of a magnifying-glass, on the posterior portion 
of a small depression on the membrana tympani, and a little be- 
hind the malleus, a very small canal, in which was perceived, 
although very indistinctly, a punctiform opening. By means of 
a very fine bristle I succeeded in entering a narrow groove, not 
more than one-third of a line long, which ran in an oblique 
direction from above downward, and somewhat anteriorly, into 
the cavity of the tympanum, so that the bristle passed immedi- 
ately beneath the handle of the malleus, and just as closely 
beneath the chorda tympani. On pushing the bristle still farther, 
it passed under the tendon of the inner muscle of the malleus. 
and struck on the inner wall of the cavity of the tympanum." 

Dr. Bochdalek also found the foramen in the opposite mem- 
brane of the same subject, as well as in sixty-three other prep- 
arations of the membrana tympani. Forty of them were from 
fresh subjects, the remainder had been preserved in alcohol. In 
two cases only the opening was not found. In both these cases 
morbid changes (thickening ?) had occurred in the drum-head. 



1 Loc. cit. - Loo. cit. 

3 Anatomie des Menscheii, p. 5C0. 4 Prag. Yiovtel. Jahrschvit't. January, 1866, 



216 KIYIXIAX FORAXE^". 

Kessel 1 believes that the foramen is the result of inflamma- 
tion. He says that he has convinced himself of the correctness 
of this view, by dissections and by examination of the living 
subject at Gruber's clinic. 

I believe in the existence of the foramen of Rivinus, from the 
clinical fact that I have heard a whistling sound, seemingly 
through the membrana tympani, in several cases, when the Val- 
salvian experiment was made, when neither myself nor other ob- 
servers could detect the slightest opening with the eye. I have 
also been startled, in one or two instances, on blowing my nostrils 
violently, by hearing the air whistle through the drum-head, as 
it seemed. On one occasion, I immediately consulted a friend 
who has large experience in examining the membrana tympani, 
and he decided that it was not perforate, as did several others 
who soon examined the ear. Indeed, I have never suffered from 
any disease of the ear, that led me to suppose the drum-head could 
be perforate. 

I cannot escape the subjective conviction, therefore, that the 
foramen of Rivinus exists, and that air may be occasionally 
heard to whistle through it, although the opening itself cannot 
be seen. 

Mr. Wharton Jones 2 described the circular and radiating fibres 
of the membrana tympani in his article on the organ of hearing. 

SirEverard Home 3 supposed that these fibres were muscular, and he thought 
that by this muscle ' ' accurate perceptions of sounds were conveyed to the inter- 
nal organ." Mr. Home admitted that the muscles of the malleus stretched and 
relaxed the membrana tympani, but only in order to bring the radiated muscle 
into a state capable of acting. 

Mr. Home reports a case of double hearing, and he explains it by a defective 
action of the radiated muscle, which was not exerted with the same quickness 
and force in one ear as in the other, so that the sound was half a note too low, 
as well as later in being impressed upon the organ. It is interesting to note that 
nearly all the cases of double hearing are observed as occurring in musicians. 

The patient, judging from the history, evidently had a catarrh of the tym- 
panic cavity, and the double hearing probably arose from unequal pressure on 
the labyrinths. 

The objects in the membrana tympani, which first strike the 
attention of the observer, are the handle, or long process of the 
malleus bone, and the triangular spot of light. I am now speak- 
ing of the membrane, when viewed through the auditory canal. 
When this is detached, the reflection called the light spot, is not 

1 Strieker's Hand-book of Histology, p. 953. 

2 Cyclopaedia of Anatomy and Physiology, vol. ii. 

3 Philosophical Transactions of the Royal Society of London, 1800. Part I. 



LIGHT SPOT. 217 

seen, because one of the conditions for its formation is removed, 
as is also true, to a certain extent, of a membrane seen after 
death, when the tissues are macerated. 

The long process of the malleus, also called the handle or 
manubrium of the malleus, divides the membrane into two parts. 
The anterior part is smaller than the posterior. The attachment 
of the malleus between the layers of the drum-head will be 
described in the description of these parts. 

At the extremity of the handle of the malleus is situated the 
apex of the light spot. This point is also the place of greatest 
concavity of the outer surface of the drum-head, and is called 
the umbo (boss of a shield), or navel of the membrane. 

The light spot, as will be seen in the chapter on chronic non- 
suppurative disease of the middle ear, is one of the important 
standpoints for the diagnosis of certain affections of the middle 
ear. The study of the conditions necessary to its formation is 
therefore of importance. 





Figs. 55, 56. — View of Membrana Tympani, showing Handle of Malleus and Triangular Spot 

of Light. 

An account of the normal color of the membrana tympani 
will be found in the chapter on chronic non-suppurative in- 
flammation. Until the investigations of Troltsch and Politzer, 
this was described as seen in the dead subject ; but the post- 
mortem appearances of this membrane, are no guide to its ap- 
pearance in the living subject. The ordinary breadth of the 
light spot, at its base, is from one and a half to two millimetres. 
— (Politzer.) It is sometimes interrupted in its continuity. 

The chief causes of the existence of the light spot, according 
to Politzer, 1 are the inclination of the membrane to the axis of 
the external auditory canal, and the concavity produced by the 
traction of the handle of the malleus. 

If light be thrown upon a dried preparation of the human oar. 
as in the examination of the living subject, through the auditory 
canal, the light spot will be found in the same position as ir is 
seen in life. It is also displaced very little by moving the eye in 



1 The Membrana Tympani, p. 2G. Mathewsoc and Newton's translation. 



218 LIGHT SPOT. 

different directions, because the axis of vision corresponds so 
nearly to the axis of the meatus, that the light spot can change 
very little with respect to the inclination to the membrana tym- 
pani. 

No light would be reflected to the eye, if the membrane were a 
plane surface ; for, with its inclination to the auditory canal, all 
rays thrown upon it would be reflected against the anterior and 
lower wall of the canal. In consequence, however, of the inward 
curvature from the traction of the handle of the malleus, its parts 
undergo such a change of inclination that the anterior portion 
stands directly at right angles to the axis of vision of the ob- 
server, and the light thrown upon it is reflected back to the eye. 

Politzer proved the correctness of this opinion by stretching 
an animal membrane over a large ring, and giving it the inclina- 
tion of the membrana tympani. No reflection will be perceived 
until the central portion is pressed inward, or made concave by 
traction from behind it. 

Helmholtz ' also states that the triangular spot of light is due 
to reflection. Yoltolini 2 claims that the light spot may be seen 
when no auditory canal is present ; indeed, even when the mem- 
brane is completely removed. This seems to me to be a mistake ; 
for while there is a reflex from any generally convex brilliant 
membrane, such as the drum-head, although it has a central con- 
cavity, there is no such triangular and fixed one, as when the 
auditory canal is present, and this is the whole point of the theory 
of Politzer. 

Voltolini is correct, however, in calling attention to other 
modifications of the light spot, than its inclination in the audi- 
tory canal. If this part of the membrane become thickened, in- 
flamed, or infiltrated ; in other words, if from mechanical or 
chemical causes it cease to be a brilliant membrane, and it does 
not reflect light as well as formerly, the light spot will no longer 
be triangular in shape, and perhaps not exist at all; but neither 
the concavity nor polish of the membrane have all to do with the 
existence of the light spot, as Yoltolini asserts. Any person can 
prove this for himself by a few simple experiments, with a mem- 
brane stretched over the end of a tube. 

The light spot depends upon three factors, viz. : 
I. The inclination of the membrana tympani to the audi- 
tory canal. 
II. The traction of the malleus, which renders it concave at 
the centre. 

III. Its polish or brilliancy. 

1 Monatsschrift fur Olirenheilkunde, Jalirgang VI., No, 8. 2 Loc. cit. 



LAYERS OF MEMBEANA TYMPANI. 



219 



THE LAYERS OF THE MEMBRANA TYMPANI. 



The membrana tympani is not quite 0.1 mm. in thickness 
(Henle)— about as thick as very fine letter-paper or gold-beaters' 
skin. This thickness varies within small limits. 

There are three layers in the structure of the membrana tym- 
pani. 

1. A thin layer of integument. 

2. A fibrous layer. This layer forms the principal thickness 
of the membrane. 

3. A mucous layer continuous with that of the tympanic 
cavity. 

The integumentary layer may be easily separated from the 
fibrous layer, but the mucous membrane is so 
closely connected to it that it is impossible to 
separate them. — (Politzer.) 

It is made up of many layers of pavement 
epithelium with a Malpighian mucous layer. It 
has, however, a very thin layer of connective 
tissue, which is arranged differently from the 
fibre of the lamina propria, and in which a con- 
stant relation to the vessels and nerves of the 
outer layer is observed. — (Politzer.) 

The first or integumentary layer of the mem- 
brana tympani has none of the hairs or glands 
of the lining of the canal, of which it is a direct 
continuation. The papillae are found as far as 
the short process of the malleus. 

The epidermal cells, the cuticle, and corium 
diminish gradually in thickness from the per- 
iphery toward the handle of the malleus; they ^Ta Tvmpani ^f^r 
then increase and are thickest on the outer edge Senle). l x 300. 
of this bone. 

The fibrous layer consists of lamellae, each one of which forms 
a mesh-work of smooth fibres with narrow, almost fissure-shaped 
apertures. The fibres have an average breadth of 0.01 mm. 

The majority of the fibres run to the malleus in a radiating or 
circular direction. A small number of them, however, run in 
different directions between these two sets of fibres. The radiat- 
ing fibres are external, beneath the cutis, the circular next to the 
mucous membrane. 

The fibres of the membrana tympani are sharply outlined 
and opaque, flattened on the sides, swelling out in the middle. 
They are from 0.003G mm. to 0.0108 mm. in thickness. Some- 




57. — Vertical 
of Fibrous 



220 LAYEES OF MEMBRANA TIMPANI. 

times they appear to be homogeneous, but they are actually 
fibrillated. Chromic acid, chloride of gold, and osmic acid 
bring out the fibrillated structure. — (Kessel.) 

The fibrous layer might be well described, according to Kes- 
sel, "as a deep layer of the corium changed and adapted for 
physiological purposes." The slits or apertures which have 
been spoken of are usually empty and appear to glisten, or on 
their edges they are covered by a finely granular mass. 

Cells are sometimes found which fill them exactly. Troltsch 
called these cells the corpuscles of the membrana tympani, and 
they are named Troltsch's cells. The larger spaces contain en- 
capsulated nuclei, and are frequently filled with amaeboid cells. 

On the periphery the thin layers of the membrana tympani 
interweave, leaving large and small spaces between the fibres 
for the passage of vessels, and form, by union with the outer 
and internal layers, the "tendinous ring," which is attached by 
means of a thin periosteum to the osseous ring, or annulus tym- 
panicus. 

All the layers of the fibrous portion are united to the osseous 
ring. Kessel confirms Gruber's observation that the circular 
fibres may be followed into the tendinous ring ; but he adds, 
' " these fibres singly, and at some distance from each other, 
pass off again from the ring at very acute angles, collect to- 
gether, and reach nearly as great thickness as that which results 
from the union of the fibres, coming from the epidermis, cutis, 
and mucous membrane." The tension of these fibres causes a 
convexity of the radii of its surface toward the meatus externus, 
giving the membrane a general convexity. The circular fibres 
do not exist on the lower third of the handle of the malleus and 
the adjacent parts. 

The organic muscular fibres described by Sir Everard Home 
have been rediscovered by Prussak, as spindle-shaped fibres in 
the membrane. 

The handle of the malleus is attached to the fibrous layer be- 
tween the radiating and circular fibres. According to Gruber, 
there is a cartilaginous formation, which begins over the short 
process of the malleus, and extends \ mm. below the handle. 
This is firmly united below ; but above, at the short process, 
there is a kind of a joint, the cavity of which is filled with syno- 
vial fluid. 

Prussak, Moos, and Kessel * say that while this cartilage ex- 
ists — that is to say, that a third of the short process is of car- 
tilage — it passes into the osseous portion without interruption. 

1 Strieker's Hand-book, p. 955. 



LAYERS OF MEMBRANA TYMPANI. 221 

There is also, according to Prussak and Moos, a thin layer of 
cartilage cells under the periosteum of the handle of the malleus 
not only in infants, but also in adults. 

Kessel found on sections of the ossicles in embryos from 
three to nine months, that the malleus is surrounded by an in- 
dependent periosteum distinct from the elements of the fibrous 
layer, and only united with the mucous layer by a duplicature 
of the mucous membrane. In place of the short process there 
are a great number of glistening nucleated cells under the peri- 
osteum and in the duplicature of tissue. These elements remain 
through life as cartilage cells, and form a solid mass with the 
osseous portion of the small process. 

At birth, the malleus is only closely united to the membrana 
tympani at two points — at the short process, and at the lower 
third of the handle. The fibrous layer is united with the perios- 
teum of the upper portion of the handle of the malleus only by 
loose connective tissue, so that a slight motion of the bone is 
possible at this point, without an articulation. 

The mucous layer consists of an epithelium and a fibrous 
framework beneath it. On the inner side of the membrane, at 
the upper part of its posterior half, is found an irregularly tri- 
angular fold, 3 mm. to 4 mm. high and 4 mm. broad, which 
arises close behind the annulus tympanicus, and extends to the 
handle of the malleus. A cavity is thus formed which opens 
below, which is called by Troltsch, 1 who described it, "the pos- 
terior pouch " of the membrana tympani. 

The best view of this duplicature is seen by viewing the 
membrana tympani from the inside, while it is still in position, 
after the roof of the tympanic cavity has been removed, and 
the incus detached from the malleus ; but it may even be seen 
from the outer surface, by a good illumination, in the living 
subject. The tissue of the pocket is the same as that of the 
fibrous layer. — (Troltsch.) 

A similar space is found in front of the malleus, but this is 
not formed by a duplicature of the fibrous layer, but by a small 
long process turned toward the neck of the malleus, by the mu- 
cous membrane that lines the tympanic cavity, and by all the 
parts that enter and leave the Glaserian fissure, that is to say 
by the long process of the malleus, by its anterior Ligament, the 
chorda tympani nerve, and the inferior tympanic artery. 

Villous processes are found on the edge o( the mucous mem- 
brane, especially in children. These processes are also found 



Von Troltsch : Lehrbuch der Ohrenheilkunde, Yierte Aufcalv, p. 88. 1868. 



222 BLOOD-VESSELS OF MEMBRANA TYMPANI. 

on the pouch of Troltsch and on the malleus. They are covered 
by flattened epithelium, and are composed of connective tissue 
in which there are capillary loops. 

BLOOD-VESSELS. 

According to the investigations of Kessel, there are blood- 
vessels, nerves, and lymphatics in all the layers of the mem- 
brana tympani. It had been previously taught by nearly all 
the writers, that there were no blood-vessels or nerves in the 
fibrous layer of the drum-head, although, according to Gerlach, 
there was a capillary anastomosis between the mucous mem- 
brane and the cutis on the periphery of the middle or fibrous 
layer. Kessel * also claims to have first described the lymph- 
vessels. 

According to Kessel, there is a direct passage of blood-vessels 
from the outer layer of the membrana tympani to the cavity of 
the tympanum ; a complete capillary network in the fibrous 
layer communicates with the cutis and the mucous membrane. 

The blood-vessels that pass from the auditory canal down 
upon the membrana tympani, come from the deep auricular 
artery, which is a branch of the internal maxillary. 

Those on the mucous membrane arise from the vessels of the 
tympanic cavity. 

The blood-supply of the outer layer of the membrane may be 
very readily traced in many cases of inflammation, or after in- 
jecting the canal with warm water. The whole circumference 
of the membrane is usually found injected in connection with 
redness of the lower part of the canal. Larger vessels run im- 
mediately behind the handle of the malleus to the umbo, where 
they pass off in radii to the edge. 

NERVES OF THE MEMBRANA TYMPANI. 

Nerves are found in each layer of the membrana tympani. 
The larger nerve-trunks accompany the chief vessels. They 
divide as these do, and frequently unite together like the capil- 
laries. They form thick networks under the epithelium of the 
cutis, and also under that of the mucous membrane. A funda- 
mental plexus, a capillary plexus near the vessels, and a sub- 
epithelial plexus may be distinguished. 

The chief nerve-trunk consists of medullated fibres, which is 
provided with a sheath of Schwann, and lies on the boundary 

1 Loc. cit. , p. 958. 



NERVES OF MEMBRANA TYMPANI. 



223 



between the cutis and the fibrous layer. It passes on to the 
membrane at the upper part of the posterior segment. Besides 
this chief trunk, several small branches enter the membrane at 
different parts of the periphery. 

In addition to the openings in the fibrous layers, with their 
contents, Kessel found a large number of nucleated swellings, 
provided with two or more processes, that unite with the nerve- 
fibres, and which lie above and between the single fibrous layers. 




Fig. 58. — The Membrana Tympani, in connection with the Ossicula Audita s of the Right 
Temporal Bone (from a photograph — Rudinger). 1, Transverse section of the fossa sig- 
moidea, in which is the transverse sinus; 2, lower section of the transverse sinus; 3, inner 
side of the transverse wall thrown back, which causes, 4, the emissarius mastoideus to be 
opened ; 5, carotid canal ; 6, the membrana tympani connected to the mucous membrane of 
the cavity of the tympanum ; 7, the malleus on the anterior and upper portion of the handle 
(the pockets of the membrana tympani are seen) ; S, the divided tendon of the tensor tympani 
muscle; 9, the incus; 10, stapes lying by the stapedius muscle, on the pyramid, which is 
opened ; 11, stapedius muscle; 12, section of facial nerve ; 13, chorda tympani nerve. 

The greater part of the cell elements found between the 
fibres of the fibrous layer, must be considered, according to 
Kessel, as belonging to the blood- and lymph-vessels, and to the 
nervous system. 1 



Kessel, in Strieker's Hand-book, p. 962. 



224 



NERVES OF MEMBRANA TYMPANI. 



The nerves of the mucous membrane of the membrana tym- 
pani are also more numerous, according to the author from 
whom I have just quoted, than has been hitherto supposed. 
There is a plexus near the vessels, and a sub-epithelial plexus. 
The former accompanies the lymph- rather than the blood-vessels. 
Its receives its fibres, in part, from threads of the tympanic 
plexus, which pass on to the membrane, with the mucous mem- 
brane, from different parts of the periphery, and partly from the 
nerves of the cutis, passing through the fibrous layer. The sub- 
epithelial plexus is a fine network directly under the epithelium, 
which it supplies with threads. 1 

The outer nerve-supply of the membrana tympani is from the 




Fig. 59. — Left Temporal Bone (two-thirds of the normal size). 1, Squamous portion of 
temporal bone ; 2, petrous portion of temporal bone ; 3, mastoid portion of temporal bone ; 
4, internal auditory canal ; 5, depression from dura mater ? 6, sup. petrosal sinus ? 7, eminence 
from semicircular canal ; 8, carotid foramen ; 9, zygomatic process ; 10, groove for meningeal 
artery ; 11, mastoid foramen ; 12, lateral sinus. 

fifth pair. The main trunk is a branch of the superficial tem- 
poral nerve, from the third branch of the trifacial or fifth nerve. 
The chorda tympani nerve runs along the inner surface of the 
membrana tympani, but gives no branches to it. 



LYMPH-VESSELS. 

They are arranged in three layers, like those of the blood- 
vessels. The first layer belongs to the cutis, the second to the 
fibrous layer, and the third to the mucous membrane. In the 
cutis they form a very fine network, immediately under the rete 
Malpighii. This network passes over the capillaries at many 
points. They gradually pass into large capillaries, which often 

1 Kessel, p. 963. 



THE TYMPANUM". 



225 



interlace with the blood capillaries, and finally unite in indepen- 
dent and larger trunks. These run either posteriorly and above, 
or, exactly like the blood-vessels, pass at various points to the 
periphery and to the auditory canal. 

In the mucous membrane, also, there is, although not in large 
number, a sub-epithelial network, lying near the tendinous ring. 
These vessels are distinguished from the blood capillaries of the 
same width by their manifold dilatations. 1 



THE CAVITY OF THE TYMPANUM. 

The tympanum {drum), cavity of the tympanum, or drum of 
the ear, is the irregular, air-containing space lying beyond the 
membrana tympani. The mastoid cells, also containing air, and 
lying in the mastoid portion of the temporal bone, are connected 
with the tympanum at its upper and posterior part ; while the 
Eustachian tube permits the entrance of air into the cavity 
through the upper part of its anterior wall. 

The points to be noted in the description of the tympanic 
cavity are indicated in the following scheme : 



THE 

TYMPANUM 

presents for ex- 
amination its 



1. Dimensions. 



2. Walls. 



3. Ossicles. 



4. Ligaments. 



5. Muscles. 



f the Anterior, 
the Posterior, 
the Outer, 
the Inner, 
the Upper, 
the Lower. 

f Malleus. 
\ Incus. 
| Stapes. 

Ligaments of mov- 
able joints. 



Ligaments of im- 
movable joints. 



Tensor Tympani. 
Stapedius. 



Malleus — In cits. 
Incus — Ti/mpan um. 
Incus — Stapes. 

Obturator Stapedis. 
Mallei Superior. 
Mallei A)iterior. 
In cud is Superior. 



6. Mucous Membrane. 

7. Vessels. 

8. Nerves. 



1 Kossel: Handbuoh der Lehre von don Geweben, p. 851, 

15 



226 



DIMENSIONS OF THE TYMPANUM. 



1. The dimensions of the tympanum, like those of the exter- 
nal auditory meatus, vary much in different individuals. The 
following table shows about the average diameters as given by 
Troltsch : ' 



Anteroposterior diameter, 
Vertical 

Transverse " 



13 mm. 

. at anterior part, . . 5 to 8 mm. 
. at posterior " . .15 mm. 
. at anterior " . . 3 to 4.5 mm. 
. opposite the drum-head, 2 mm. 



2. The anterior wall presents, at its upper part, an opening of 
considerable size — the tympanic orifice of the Eustachian tube. 
Below this is a strong bony plate. 

The measurements of a cast of the tympanic cavity repre- 
sented on page 93, are as follows : 

Distance from attachment of upper part of the membrana 
tympani to the superior margin of the opening of the Eustachian 
tube, 1^ line ; from opening of mastoid cells above to the supe- 
rior margin of the opening of Eustachian tube, oh lines ; from 
opening of mastoid cells below to the inferior margin of the 
opening of the Eustachian tube, 6^ lines ; vertical diameter of 
the tympanic cavity, 6 lines ; distance from the membrana tym- 
pani to upper inner wall, 2 lines ; to lower inner wall, 1 line ; 
opening of Eustachian tube, vertical diameter, 1J line ; horizon- 
tal diameter, 1 line. A plaster of Paris cast contracts somewhat, 
so that these measurements are actually too small. 

The posterior icall separates the cavity of the tympanum 
from the mastoid cells. The opening into the cells is at its 
upper part, close under the roof, and considerably higher than 
the orifice of the Eustachian tube. 

The outer wall of the tympanic cavity is composed, for the 
most part, of the membrana tympani ; but it extends much 
further backward than the membrane, and contains three small 
openings : the aperture of the iter chordae posterius, the Glaser- 
ian fissure, and the aperture of the iter chordae anterius. 

The opening of the iter chordae posterius is on a level with 
the centre of the membrana tympani and close to its margin, 
and gives entrance to the chorda tympani nerve. The nerve 
then runs upward under the long process of the incus, on the 
free margin of the posterior pocket of the membrane, then for- 
ward across the neck of the malleus, and finally enters the iter 
chordae anterius, or canal of Huguier. The Glaserian fissure 



1 Text-book, translation, p. 171. 



FENESTRA OVALIS AND FENESTRA ROTUNDA. 



227 



opens above, and in front of, the membrana tympani ; while 
just above it is seen the aperture of the iter chordae, anterius. 

The inner wall of the tympanum is the outer boundary of 
the labyrinth, and consists of bone. It has two small apertures 
closed by membranes. The upper and larger opening is called 
the fenestra ovalis, or oval window, and leads into the vesti- 
bule ; while the lower and smaller one is called the fenestra 




Fig. 60. — The Right Temporal Bone, with the Membrana Tympani and Ossicula Auditus of 
an Adult. 1, Squamous portion — under figure 1 the sulcus of the transverse sinus runs down- 
ward ; 2, a bristle passes through the mastoid foramen ; 3, mastoid cells ; 4, antrum of the 
mastoid, communicating both with the mastoid cells and with the tympanic cavity ; 5, styloid 
process ; 6, membrana tympani — a point of mucous membrane of the tympanic cavity is sees 
under the number 6 ; 7, the malleus — under the chorda tympani we see the divided tendon of 
the tensor tympani muscle; 8, the incus; 9, the short process ; 10, the chorda tympani nerve; 
11, the stapes ; 12, stapedius muscle; 13, facial nerve; 14, stapedius nerve, branch of facial. 
The relations of the mastoid cells to the cavity of the tympanum and the relations of the 
former to the transverse sinus are well shown. (After liiidinger. ) 

rotunda, or round window, and communicates with the cochlea. 
The former is closed by the periosteum of the vestibule, to which 
the base of the stapes is attached. The fenestra rotunda lies 
below the fenestra ovalis. and is closed by the membrana tym- 
pani secundaria. Both these openings may perhaps more prop- 
erly be called canals, since they have considerable depth, the 
membranes which close them lying at their inner extremities. 



228 ANATOMY OF TYMPANUM. 

In front of the fenestrae, and partly between them, lies the 
promontory, a projection of the first whorl of the cochlea. 
Upon it may be seen three shallow grooves for branches of the 
tympanic plexus. In front of the promontory the inner wall of 
the tympanum consists of a very thin plate of bone separating 
this cavity from the carotid artery. This plate is pierced by 
many minute openings for vessels and nerves, and has, besides, 
many irregularities on its tympanic surface. 

Just above and behind the fenestra ovalis, is a slight rounded 
ridge, corresponding to the aquceductus Fallopii, which gives 
passage to the facial nerve. This canal is covered by an ex- 
tremely thin plate of bone. Behind and below the fenestra 
ovalis is the pyramid, a hollow, bony projection containing the 
stapedius muscle. The bottom of this cavity of the pyramid is 
in communication with the aquaeductus Fallopii, by means of a 




Fig. 61. — Section of Right Temporal Bone (actual size. From Professor Darling's mu- 
seum). 1, Cochlea ; 2, external auditory canal ; 3, attachment of membrana tympani to bony 
ring ; 4, head of malleus ; 5, tympanic cavity ; 6, mastoid cells. 

minute canal. Just behind the ridge of the Fallopian canal, and 
about on a level with the fenestra ovalis, is seen a hard, smooth, 
bony surface, which corresponds to the external or horizontal 
semicircular canal of the labyrinth. 

The upper wall, or roof of the tympanum, is the partition be- 
tween this cavity and that of the cranium. Its thickness and 
density vary considerably in different subjects. It is sometimes 
very thin and porous, or entirely wanting, so that the tym- 
panum forms a part of the cranial cavity. 

The lower wall, or floor of the tympanum, separates this 
cavity from the jugular vein. Like the roof, it varies greatly 
in thickness, being sometimes wholly membranous. It is very 
irregular on its upper or tympanic surface ; and lying much be- 
low some points in the floor of the external auditory meatus, 
and below the orifices of the Eustachian tube and mastoid cells, 



PATHOLOGICAL CONDITIONS OF TYMPANUM. 



229 



it is usually covered, in cases of purulent affections of the 
middle ear, by a large quantity of pus. It is perforated by the 
glossopharyngeal nerve and a minute vessel. 

Studied with an eye to pathological conditions, some of these 
walls present very important relatioDS. Thus the roof of the 
tympanum lies in contact with the meninges of the brain, so 
that in caries of this wall the patient may die of purulent men- 
ingitis or cerebritis. Again, caries of the lower wall may be 
followed by phlebitis of the jugular vein ; while caries of the 




Fig. 62. — Section through Tympanic Cavity, Left Temporal Bone (posterior half, actual 
size. From Professor Darling's museum). 1, Squamous portion of temporal bone ; 2, mastoid 
cells ; 3, jugular fossa ; 4, canal for Jacobson's nerve ; 5, carotid foramen ; 6, aquaBductus 
Fallopii ; 7, fenestra ovalis ; 8, fenestra rotunda ; 9, promontory ; 10, Eustachian tube. 



inner wall has sometimes caused destruction of the coats of the 
carotid artery and fatal hemorrhage, also a suppurative inflam- 
mation of the labyrinth, with extension into the cavity of the 
skull. It is easy to see, too, how even a non-suppurative in- 
flammation of the tympanum may affect the facial nerve, since. 
during a part of its course, the nerve is separated from the mu- 
cous membrane only by a thin plate of bone, which may even 
be deficient in many places. Indeed, swelling of this nerve. 
causing temporal facial paralysis, or destruction of it. producing 
permanent paralysis, is not uncommon in connection with a 
suppuration in the middle ear. 



230 OSSICULA AUDITUS. 



OSSICULA AUDITUS. 

3. The three small bones of the ear, the ossicula audit us, 
which serve for the conduction of the sonorous undulations 
through the tympanum to the labyrinth, are the malleus, or 
hammer ; the incus, or anvil ; and the stapes, or stirrup. 

The ossicles are articulated to each other, and extend, al- 
though not in a straight line, from the membrana tympani to 
the fenestra ovalis. 

The malleus may be described as consisting of the head, 
neck, short process, manubrium or handle, and the long process 
or processus gracilis. 1 The head is the larger, upper extremity 
of the bone. Posteriorly it has an elliptical depression, twice or 
thrice as long as it is broad, and of considerable depth for artic- 
ulation with the incus. Below the head is a constricted por- 
tion called the neck, and just below this, and on the upper end 





Fig. 63.— Tympanic Cavity, -with Ossi- Fig. 64.— Anterior Surface of Malleus 

cles in situ (actual size. From Professor and Incus. Articulated (twice size. From 

Darling's museum). 1, Fenestra rotunda ; Professor Darling's museum). 1, Short 

2, promontory ; 3, annulus tympanicus ; 4, process of malleus ; 2, head of malleus ; 3, 

incus ; 5. handle of malleus ; 6, stapes ; 7, handb of malleus ; 4. broken processus 

head of malleus. gracilis ; 5, long process of incus ; 6, short 

process of incus ; 7, body of incus. 

of the manubrium, is a prominence to which the processes are 
attached. The manubrium extends downward and inward, be- 
ing inserted into the drum-membrane between the circular and 
radiating fibres of the middle layer. The processus gracilis 
passes from the eminence below the neck forward and outward 
to the Glaserian fissure. The short process lies at the base of 
the manubrium opposite where it gives attachment to the ten- 
sor tympani. 

The incus lies just back of the malleus, and may be described 
as having a body and two processes. On the anterior and inner 
surface of the head is seen the surface for articulation with the 
malleus. The short process projects backward and articulates 
with the posterior wall of the tympanum. The long process, 

1 Some writers call the handle of the malleus the long process. 



OSSICULA AUDITUS. 



231 



much more slender than the other, descends at a right angle 
with the short process, and parallel with and behind the manu- 
brium, to end in the processus lenticularis, which articulates 
with the head of the stapes. This articulation lies a little higher 
than the tip of the manubrium. 

The stapes consists of the head, neck, crura, and base, and 
is the innermost and smallest of the bones of the ear, and in- 







Fig. 65. — Ossicles of the Tympanum (actual size and twice the size. From Professor Dar- 
ling's museum). A, Malleus. 1, Short process, processus brevis ; 2, head ; 3, processus gra- 
cilis ; 4, handle, manubrium. B, Incus. 1, Body ; 2, short process, processus brevis; 3, long 
process, processus longus. C, Stapes. 1, Head ; 2, base. 




deed of the body. The head presents on its outer part a surface 
for articulation with the lenticular process of the long process 
of the incus. Just internally to the head is the constricted por- 
tion called the neck, into which is inserted the stapedius muscle. 
From the neck the crura diverge horizontally, the one forward 
and inward, the other backward and inward, to 
be inserted into a thin plate constituting the 
base, which lies upon the membrane of the fen- 
estra ovalis. On the outer side of the base is a 
delicate ridge running from the extremities of 
the crura and into which is inserted the obtura- 
tor stapedis. 

The dimensions of the ossicles are : length of 
malleus from summit of. head to short process, 
about 4-J mm. ; from short process to the end of 
the handle, 4 to 5 mm. Long process or handle, 
about 2 mm. Length of the incus from summit of head to the 
end of the long process, about 6£ to 7 mm. ; to the end oi the 
short process, about 5 mm. Length of the stapes, about 3 mm. 
Greatest distance between the crura, about % mm. Length of 
the base, about 3 mm. ; width, about 1 mm. The long process. 
or processus gracilis, is sometimes called the processus Folianus 
(Ccelius Folius, Venice, 1045), and also the process o( Ran. after 
Professor Jacob Ran, of Leyden. 

4. Of the ligaments of the ossicles we have two classes . the 



Fig. 66.— Poste- 
rior Surface of the 
Malleus, Incus, and 
Stapes. Articulated 
(twice the natural 
size). 



232 LIGAMENTS OF OSSICULA AUDITUS. 

ligaments of the movable joints and those of the immovable 
joints. 

The malleo-incus joint may be classed with the gynglimus 
articulations on account of the character of the articulating sur- 
faces. These surfaces are covered by cartilage about 0.04 mm. 
in thickness. The capsule is tense. This joint is provided with 
synovial membrane. 

The articulation between the short process of the incus and 
the posterior tympanic wall is an amphiarthrosis, and is sur- 
rounded by a tolerably thick and tense capsule. The motion is 
quite restricted. 

The joint between the processus lenticularis of the incus and 
the head of the stapes is an arthrosis, the processus lenticularis 
corresponding to the ball and the head of the stapes to the socket. 
Both surfaces are covered with cartilage. The cartilage is much 
more delicate than those of the other joints, and is characterized 
by being rich in elastic fibres. 

The ligamentum obturatorium stapedis is a thin membrane 
inserted into the ridge on the outer side of the base of the stapes 
and into the inner edges of the crura, closing the opening formed 
by these parts. 

The head of the malleus sometimes lies in contact with the 
roof of the tympanic cavity. More frequently it is connected 
with the roof by the cylindrical lig. mallei super ius (Soemmering). 
The neck of the malleus is held in place by the cartilage which 
sometimes takes the place of the long process, and by the lig. 
mallei anterius (Arnold), which goes from the spina angularis 
of the sphenoid parallel with the fissura petro-tympanica, to be 
inserted upon the head of the malleus. 

The incus, when not in immediate contact with the roof of 
the tympanum, is attached to the roof by means of the lig. in- 
cudis superius (Arnold), and is inserted into the posterior border 
of the body of the bone. 

The posterior surface of the head of the malleus is oblong, 
and it extends in spiral form from above downward and inward 
to the boundary of the neck. It consists of two surfaces, which 
meet in an almost vertical edge. The incus has an articular sur- 
face corresponding to this. These surfaces are covered by a thin 
layer of hyaline cartilage. The capsular ligament connecting 
the bones allows of considerable motion. A fold, described by 
Pappenheim (1840) and Rudinger, projects into the cavity of the 
joint. 

The mechanism of the joint between the malleus and incus is 
compared by Helmholtz to the cog contained in certain watch- 
keys, where the handle cannot be turned in one direction without 






ARTICULATIONS OF OSSICLES. 233 

carrying the steel shell with it, while in the opposite direction it 
meets with only slight resistance. When the handle of the 
malleus moves inward, the inferior cog of the malleus catches 
the inferior cog of the incus, and causes the long process of the 
incus to follow the motion of the handle of the malleus inward. 
When the handle of the malleus moves outward, a strong move- 
ment of the articular surfaces follows, the inferior cog of the 
malleus recedes from that of the incus, and the incus will con- 
sequently only follow the motion of the malleus outward to a 
slight extent. ' 

The articulation of the incus and stapes does not admit of 
much separation of the bones, but they can move sideways to a 
greater extent. 

The articulation between the stapes and the margin of the 
fenestra ovalis has been the subject of much microscopical 
study by Eisell, Buck, and Brunner. The tissue connecting the 
margin of the fenestra ovalis with the margin of the foot-plate 
of the stapes consists of elastic fibres, which run in a radiat- 
ing direction, converging toward the margin of the foot-plate. 
These margins are covered with a thin layer of cartilaginous 
tissue. Voltolini denies that there is cartilage in this articu- 
lation. 

The stapedius muscle arises from the bottom of the pyramid, 
or eminentia stapedii, the hollow of which it fills. At the ori- 
fice of the canal it becomes tendinous, and thence runs, at an 
obtuse angle with the rest of the muscle, to the neck of the sta- 
pes. This is the smallest distinct muscle of the human body. 

Although it has been a matter of discussion as to whether 
the lining membrane of the tympanic cavity is a mucous or 
serous membrane, Politzer, from his own investigations, has no 
doubt but that it is a mucous membrane. He thus agrees with 
Krause, Troltsch, and Wendt, who found mucous glands in the 
tympanic cavity. According to Politzer, vascular folds of mu- 
cous membrane extend from the walls of the tympanic cavity 
to the ossicles. These folds are the means of connecting the 
vessels in the coverings of the ossicles and those of the walls of 
the cavity. Besides these folds, Politzer found a number of in- 
constant prolongations of connective tissue, which were for- 
merly supposed to be pathological products, but which, as ho 
was the first to prove, are the remains of the gelatinous connec- 
tive tissue which fills the middle ear of the feetus. 

Sometimes the anterior portion of the tensor tympani is con- 
nected with the tensor veli palati. According to Politzer, in 



Lohre von den Tonempfindungen, p. '-217. 



234 MUCOUS MEMBPwANE OF TYMPANUM. 

the new-born infant there is an immediate communication be- 
tween the lower portion of the muscular cavity and the facial 
canal. In adults, there are one or more oblong fissures be- 
tween the eminentia stapedii and the facial canal. In these 
fissures the fibrous coverings of the connective tissue of the 
muscle and the nerve come in contact and amalgamate. 1 

5. The tensor tympani muscle arises in front of the anterior 
opening of the canalis musculo-tubarius from the pyramid of the 
temporal bone, from the upper wall of the tubal cartilage, and 
from the neighboring border of the sphenoid. It passes over the 
septum tubse into and through the canal of the tensor tympani. 
Just before leaving the canal it becomes tendinous. The tendon 
is inserted on the inner margin of the handle of the malleus, at 
the anterior edge of the rhomboidal surface, obliquely to the 
longitudinal axis of the malleus. 

6. The mucous membrane of the tympanum is a continuation 
of that of the Eustachian tube and naso-pharyngeal space. It 
is extremely delicate and consists chiefly of an epithelium and 
a layer of connective tissue underneath. On the lower, the an- 
terior portion of the inner, and the posterior walls, the epithe- 
lium consists mainly of columnar cells ; while on the promon- 
tory, roof, membrana tympani, and ossicles, pavement cells 
predominate. The thinness of the connective tissue is such 
that Von Troltsch asserts that the mucous membrane cannot be 
separated from the periosteum, and that every catarrh is a peri- 
ostitis. But, according to Kessel, the connective tissue of the 
mucous membrane in some places forms a fibrous framework 
which separates it from the periosteum, and passes from one pro- 
jection of bone to another through the free space of the cavity. 
One such bridge has frequently been observed to pass from the 
eminentia pyramidalis to the processus cochleariformis, while 
many are seen on the floor of the tympanum. 

BLOOD-VESSELS. 

The anterior and middle parts of the tympanic cavity are 
supplied — 

1. By the branches of the ascending pharyngeal artery, from 
the external carotid. 

2. By branches of the middle meningeal, which pass through 
the hiatus canalis Fallopii and the petroso- squamosal fissure 
into the tympanic cavity. 

3. By the internal carotid, which sends a few small branches 
from, the carotid canal into the tympanic cavity. 

1 Diseases of the Ear, translation, p. 43. 



BLOOD-VESSELS AND NERVES OF TYM PAN UN. 235 

Politzer l has shown that there is a vascular communication 
between the middle ear and the labyrinth, through the osseous 
wall separating them. He says that the blood-vessels of the 
middle ear can be seen proceeding from the deeper layers of the 
lining membrane, accompanied by numerous prolongations of 
connective tissue and penetrating almost perpendicularly into 
the bony substance. The blood-vessels of the bony wall thus 
connect the blood-vessels of the mucous membrane of the middle 
ear with the vessels of the labyrinth. 

This vascular connection readily explains the easy trans- 
ference of disease of the middle ear to the internal ear, a fre- 
quent clinical experience. Yet the communication is not so easy 
as to make it certain to occur in every case. 



NERVES. 

The tensor tympani muscle is supplied by a branch from the 
otic ganglion, and from the internal pterygoid, a branch of the 
third division of the trifacial. 

The stapedius is supplied by a filament from the facial nerve. 

The nerves of the mucous membrane are derived from the 
tympanic plexus, consisting of a combination of the great sym- 
pathetic, the trifacial, and the glossopharyngeal. 

The nerves that make up the tympanic plexus, according to 
Von Troltsch, 2 are — 

1. Several carotico - tympanic nerves, branches from the 
plexus of the sympathetic in the carotid canal, which enter the 
cavity of the tympanum through special foramina. 

2. A twig of the superficial petrosal nerve, entering the 
cavity from above. It is regarded by some as a connection be- 
tween the otic ganglion and bend of the facial. Others consider 
it a continuation of the tympanic nerve (Jacobsoirs) to the otic 
ganglion. 

3. The ramifications of the tympanic nerve, arising from the 
giosso-pharyngeus. 

The otic ganglion is situated near the foramen ovale of the 
greater wing of the sphenoid bone, in front of the middle men- 
ingeal artery, on the outer side of the cartilage of the Eusta- 
i chian tube, and the point of origin of the tensor palati muscle. 

It is made up of motor fibres from the third division o( the 
fifth nerve, of sensory fibres from the glosso-pharyngeal, and of 
fibres from the great sympathetic. 

1 Arclriv fiir Ohrenheilkunde, vol. xi. 

2 Treatise on the Ear, translation, \\ 5>7. 



236 MASTOID PROCESS. 

Its branches of distribution are to the tensor tympani and 
the tensor palati muscles. It sends a twig to the external 
pterygoid branch of the fifth nerve, and several communicating 
branches to the auricular nerve of the third branch of the fifth 
nerve. 

By this ganglion the soft palate, the drum-head and tensor 
tympani, and the integument of the external ear are put in re- 
lation with each other and with the general nervous system. — 
(Troltsch.) 

The chorda tympani nerve seems to pass through the tym- 
panic cavity without being in any physiological relation to it. 
Division of this nerve in operations upon the tensor tympani 
muscle usually has no effect upon the functions of the ear. ' 

Prussak's experiments on dogs show that irritation of the 
cervical sympathetic by the galvanic current causes contraction 
of the blood-vessels. When the irritation ceased considerable 
expansion occurred. 



THE MASTOID PROCESS. 

The mastoid portion of the temporal bone (juaoro?, a nipple or 
teat) is situated at the posterior part of the temporal bone. Its 
external surface is rough, and perforated by numerous fora- 
mina. One of these, of large size, situated at the posterior bor- 
der of the bone, is called the mastoid foramen. Through it 
a vein passes to the transverse sinus and a small artery. 

This roughened appearance of the mastoid is sometimes so 
marked that it resembles the inner cellular structure of the bone. 
In some rare cases there is even complete absence of the outer 
layer of bone, so that the air cavities open externally, as well 
as into the cavity of the tympanum and the external auditory 
canal. 

Gruber 2 has seen emphysema of the neck and of the occipi- 
tal region result from the inflation of the cavity of the tym- 
panum in cases where such external openings existed under the 
skin. 

This foramen does not always exist in the mastoid process, 
but is sometimes found in the occipital bone, or in the suture 
between the temporal and the occipital. 

The mastoid portion is continued below into a conical pro- 
jection, which is the true mastoid process. To this process are 

1 See Chapter X. for an account of the functions of the chorda tympani. 

2 Lehrhuch, p. 32. 



MASTOID PIIOCESS. 



237 



attached the sterno-mastoid, the splenius capitis, and trachelo- 
mastoid muscles. 

On the inner side of the mastoid process is a deep groove, 
called the fossa sigmoidea. In this groove is a part of the lat- 
eral sinus, and the mastoid foramen opens into it. The mastoid 




Fig. 67. — Vertical Section through Right Temporal Bone (anterior surface of posterior 
half, two-thirds size. From Professor Darling's museum). 1, External auditory canal ; 2, 
internal auditory canal ; 3, tympanic process ; 4, sup. semicircular canal ; 5, vestibule ; (5, 
styloid process ; 7, mastoid cells ; 8, tympanic cavity. 

process is hollowed out into a number of spaces of various size, 
which are called the mastoid cells. 



THE MASTOID CELLS. 

The upper or horizontal part of the process, called also the 
antrum mastoideum, is in communication with the tympanum 
by means of one or more openings in the posterior tympanic 
wall ; and since it exists even in the infant, before the develop- 
ment of the mastoid process, it lias been suggested that the 
name of ''upper cavity of the tympanum " would be more ap- 
propriate. The second part of these cells, lying in the mastoid 



238 MASTOID CELLS. 

process of the temporal bone, are below the horizontal part. 
The whole consist of a great number of irregular spaces of vary- 
ing sizes — sizes that also vary much in different individuals. 
The whole are enclosed by a dense cortical layer of bone, sepa- 
rating them from the cavity of the skull, and limiting them ex- 
ternally. This cortical layer also is of different thicknesses in 
different individuals, a fact of some practical importance in 
cases of suppurative inflammation of the middle ear, implicating 
these cells. Several small foramina are seen in the mastoid por- 
tion of the temporal bone — openings for branches of the middle 
meningeal artery and the vasa emissaria Santorini. 

The cells are lined by a mucous membrane similar to that of 
the membrana tympani, but it is more delicate. 

The epithelium consists of smooth cells of the same consis- 
tency and arrangement as those of the membrana tympani. 
Under this we find two layers of connective 
tissue, corresponding to the periosteum. 
The latter layer contains numerous nerves, 
and blood- and lymph-vessels. The upper 
layer very frequently separates itself at the 
free edge of the cells, like a membrane, and 
becomes attached to more closely lying tips 
or projections of bone. By this means the 
cavities of two cells lying next each other 
become separated. In the larger cells these 
Fig 68 —External Sur- membranes are stretched horizontally, like 
face of Left Mastoid Bone curtains, by means of processes which arise 

(from Professor Darling's f r0 m them.— (KeSSel. 1 ) 

Z££J^?SZJl At birth the mastoid process is but the 

emissary vein; 3, mastoid rudiment of what it is afterward to be. It 
process ; 4, external auditory j s a sma ll tuberosity, and contains but one 

SSSi^t^atST cel1 of an ^ considerable size, which after- 
ward becomes the mastoid antrum. 
Dr. E. Zuckerkandl 2 was induced, by finding what seemed to 
him a remarkable specimen, taken from a man who died in 
middle life, to reinvestigate the anatomy of the mastoid pro- 
cess. In the first specimen that attracted his attention he found 
the cells even into the antrum filled with diploetic tissue, and 
the adjacent ones to this latter part also containing fat. The 
fat and diploe were just the same in appearance with that of 
other fresh bones. The other parts of the ear were sound. There 
was no trace of a pathological cause. His subsequent exami- 

1 Handbucli der Lehre von den Geweben. Vierte Lieferung, p. 864. 

2 Monatsschrift fur Ohrenlieilkunde, vol. xiii., No. 4, 1879. 




VARIETIES ITT MASTOID. 



239 



nations showed him that in many cases the mastoid process was 
entirely diploetic in structure or fully plugged with fat, and that 
these tissues appeared together and in connection with air-cells. 
Zuckerkandl examined 250 ears. He found that the external 
appearance gave no positive indication of the internal structure. 




Fig. R9. — Vertical Section through Right Temporal Bone (posterior half, actual size. From 
Professor Darling's museum). 1, Squamous portion of temporal bone; 2, mastoid process: 
8. external auditory canal ; 4, internal auditory canal ; 5. carotid canal ; 6, eminence of sup. 
semicircular canal ; A, A, aquseductus Fallopii ; B, B. sup. semicircular canal ; C, C, hori- 
zontal semicircular canal ; 7, mastoid cells. 



He found the following varieties in the examination of 250 tem- 
poral bones : 

1. The whole process filled with air-cells. The air-spaces 
more or less of the same size. The surface thin, in spots trans- 
parent. 

2. The process containing air-cells, but the cavities small. 

3. The cells of unequal size. Generally those of the pars 
squamosa were larger. 

4. The process entirely an air-chamber (til toto lufthaltig). 



240 



VAEIETIES 13" MASTOID. 



The cells are large and extend to a line drawn from the lower 
wall of the auditory canal through the mastoid process. 

5. The cells of the pars squamosa were large, while the pars 
petrosa of the apophysis contained one large cavity. 

6. There were in the whole process only three or four tubular 
cavities, whose termini made up the antrum. 

7. The process involved only one cavity, on whose walls were 
ridge-like partitions. 

The varieties in diploetic and fatty contents were equally 
great. Of 100 temporal bones belonging to 50 subjects, the mas- 
toid process was completely pneumatic in but 40 cases. In 22 
cases, the process up to the antrum contained red or yellow 




Pig. 70. — Vertical Section of Left Temporal Bone (actual size. From Professor Darling's 
museum). 1, Cochlea with lamina spiralis ; 2, external auditory canal ; 3, opening of mastoid 
cells ; 4, plate of bone separating the tympanic cavity from carotid canal ; 5, squamous por- 
tion of temporal bone ; 6, mastoid process ; 7, tympauiu cavity ; 8, aquasductus Fallopii. 



adipose tissue. Nine times the lower half of the process was 
diploetic or contained fat, while the upper part was pneumatic, 
and in the remaining 29 cases only the apex, of from 3 to 5 
mm. was narrow-celled, diploetic ; otherwise it contained air- 
cells. In 8 of the 100 cases the mastoid processes of the same 
person were different in structure. In 150 macerated temporal 
bones the results were as follows : Fifty-two times the process 
was completely filled with pneumatic spaces. Twenty times 
only the lower half contained diploetic spaces, while the upper 
was pneumatic. Thirty-eight times the apex only of the process 
was diploetic from 3 to 5 mm. Seven times the diploetic structure 



VARIETIES IN MASTOID. 241 

extended only to the pars petrosa of the process. In summing 
up, there are found to be entirely pneumatic processes in 36. 8 
per cent. Completely diploetic, 20 per cent. In 42.8 per cent, 
diploetic and pneumatic cavities existed together in the same 
bone. These investigations make it probable that many, if not 
all, of the reported cases of hyperostosis or sclerosis of the mas- 
toid were really only normal conditions. 

Dr. Giovanni Zoja, : of Pavia, examined sixty-eight fresh 
preparations, and one hundred dry ones, in order to get the 
average size of the mastoid process and its cavities. The result 
of his investigations is that the breadth of the mastoid is 19 mm., 
its thickness 13 mm., and its length 12 mm. About one milli- 
metre should be deducted from these measurements in the bone 
of the female subject. Zoja does not confirm Yelpeau's view, 
that the mastoid process is more developed in advanced life. 
The cortical layer, according to these examinations, has an aver- 
age thickness of from one to two millimetres. 

In two of the sixty-eight specimens belonging to one subject 
the cells were united into one large cavity, so that they formed, 
as it were, a mastoid cavity. This was also found in another 
case on one side only. The cells in the centre of the process are 
usually the larger, and communicate with one another, if they 
are not separated by the membrane that has been described. In 
several cases there were cells only in the base of the process. 
Occasionally these cells extended to the side of the skull, or even 
to the middle of the petrous part of the temporal bone. 

Dr. Zoja thinks that the development of the cellular structure 
goes on in a kind of system. They become gradually larger, 
and are lined with a peculiar membrane ; in the spaces a gela- 
tinous mass is found, which becomes gradually serous, and is 
either taken up by the vessels of the cavities or passes into the 
cavity of the tympanum, where it is absorbed. 

In five of the sixty-eight specimens the antrum was found to 
be separated from the other cellular spaces by a membranous 
partition. 2 



BLOOD-VESSELS OF THE MASTOID TROCESS. 

The blood-supply of the mastoid cells is furnished by the 
stylo-mastoid branch of the posterior auricular artery, while 
their nerves come from the tympanic plexus. 



1 Gruber'a Lehrbuoh, p, 33. 
- Henle : Lehrbuoh, p, 751. 

1G 



242 



EUSTACHIAN TUBE. 



THE EUSTACHIAN TTBE. 

The Eustachian tube, like the external auditory meatus,, con- 
sists of an osseous and a cartilaginous part. The former meas- 




Fig. Tl. — Section of the Head, showing the Divisions of the Ear and the Naso-pharyngeal 
Cavity (after a photograph — Rudinger). 1, Cartilage of external auditory canal ; 2, osseous 
auditory canai ; 3. 4, membranae tympanorum ; 5, cavity of the tympanum ; 6, dilator muscle 
of the Eustachian tube ; 7, levator paiati muscle ; S. mucous membrane of the pharyngeal 
orifice of the tube ; 9. left membrana tympani ; 10, handle of the malleus and short process ; 
11, tensor tympani muscle; 12, mucous membrane of the membranous portion of the tube, 
perforated by a needle ; 13, levator veli paiati muscle ; 14, mucous membrane of the posterior 
surface of the pharynx ; 15. mucous membrane of the pharynx, attached to the lower surface 
of the body of the sphenoid bone ; 16. sphenoidal sinus ; 17, hypophysis cerebri and its rela- 
tions to the cerebral arteries and the cavernous sinus. 

ures 11 mm., the latter 24 mm., so that the whole length of the 
tube, from its opening into the tympanic cavity to its pharyngeal 
orifice, measures 35 mm. The tube, from its tympanic end, 



EUSTACHIAN TUBE. 



243 



runs forward, inward, and downward. Its axis makes an angle 
of 135° with the axis of the external auditory canal, and an angle 
of 40° with the horizontal plane. 

The diameter of the osseous portion of the tube is about 
2 mm. The walls are smooth, and covered by a mucous mem- 
brane, which, like that of the tympanum, is closely adherent to 
the periosteum. The lateral wall belongs to the pars tympanica ; 
the median wall separates the tube from the carotid canal ; the 
upper wall is formed by the septum tubse, the floor of the canal 
for the tensor tympani muscle. 

The shape of the anterior extremity of the osseous tube is 
very irregular, the inner wall extending forward much further 
than the lateral wall. This part, " the 
isthmus," is the narrowest portion of 
the tube. Here the tube gradually 
widens, and. ends anteriorly in a trum- 
pet-shaped orifice 9 mm. high and 5 
mm. broad, which projects slightly 
into the post-nasal space, and lies a 
little above the level of the floor of the 
nostril. 

The cartilage of the tube is made 
up of two plates — a median and a 
lateral. The median plate, which is 
much the larger, is triangular, and 
into its upper and outer part is inserted 
the hook-shaped and smaller lateral 
cartilage. But most of the lateral 
wall and all of the lower is formed of 
membrane instead of cartilage, the 
membrane forming nearly a half of 
the circumference of the tube. 

The median wall of the cartilage 
of the tube is below 1 mm. in thickness on its posterior extrem- 
ity, but increases in size gradually to 2£ to 3 mm., and on its 
free anterior border may even reach 7 mm. The tissue of the 
cartilage is chiefly hyaline, but it has a fibrous base substance 
at various spots ; sometimes on the surface, sometimes on the 
interior, and especially near the edges. 

The mucous membrane which fills up the concavity of the 
cartilage, and which changes the calibre up to the vicinity of 
the pharyngeal orifice to a plane surface, is 0.6 mm. thick at its 
densest portion. It is connected to the perichondrium by loose 
connective tissue. It is made smooth by numerous acinose 
glands of about 0-0 mm. in diameter and 0. L5 mm. in thickness. 




Fig. 72. — Transverse Section of 
Upper Part of the Eustachian Tube 
(after Henle). * Fibres of the 
spheno-staphylinus muscle. 



244 



EUSTACHIAN TUBE. 



These glands form a continuous layer backward from the phar- 
yngeal orifice^for some distance. Toward the cavity of the tym- 
panum they are less numerous, yet, according to Yon Troltsch, 
they are found on the tympanic orifice. Toward the pharyngeal 
orifice large mucous glands appear lying on the outer side of the 
cartilage. 

The lateral wall of the tube, which, with its upper border, 
bounds the convex surface of the enveloping ridge of the car- 
tilage, has about the same thickness as the median wall, and the 
same covering of mucous membrane. The tissue in the upper 
half is quite firm, in the lower more relaxed and spongy. Fat is 
its chief structure. 

A portion of the tendinous origin of the spheno-staphylinus 
muscle unites with the firmer portion of the wall, and for some 





Fig. 73. — Transverse Section through the 
Lower End of the Eustachian Tube (after 
Henle). * Mucous glands ; ** fibres of petro- 
staphylinus muscle. 



f * 



Fig. 74. — Transverse Section through 
the Lower End of the Eustachian Tube (af- 
ter Henle). *, Mucous glands; ** trans- 
verse section of the petro-staphylinus 
muscle. 



distance this origin runs in a thin layer between the upper bor- 
der of the soft wall of the tube, and unites with the convex sur- 
face of the latter. 

The spheno-staphylinus muscle being thus attached to the 
tube has the power of rolling over the upper inverted border of 
the cartilage, and of enlarging the angle which the lateral wall 
forms with the median. The opening or gaping of the tube de- 
pends upon this action, which occurs with the act of swallowing. 

At the point where the lateral wall of the nasal cavity passes 
into the pharynx, at the same height with the posterior point of 
the inferior turbinated bone, lies the pharyngeal orifice of the 
tube (Fig. 75). 

Since the inner wall of this canal projects into the calibre of 
the naso-pharyngeal space, the mouth of the tube lies more in a. 



EUSTACHIAN TUBE. 245 

frontal than sagittal plane. It has a puffy median border, while 
the lateral wall passes without any distinct line of separation 
into the nasal cavity. The width of the mouth of the tube 
varies in different persons, and has the general shape of a 
funnel. 

According to Riidinger, 1 the minute differences in form of 
the Eustachian tube in animals are so characteristic, that from a 
section of the Eustachian tube the animal from which it has 
been taken can be designated. 

The known functions are to conduct away the secretions of 
the cavity of the tympanum, and to act as a ventilator of this 
part. What part it has to do with the conduction of sound to 




Fig. 75. — Vertical Section showing the Mouth of Eustachian Tube and Rosenmiiller's Fossa. 

the ear, or what connection it has with the voice, has not as yet 
been determined. Riidinger has observed fatty degeneration of 
the tubal cartilage of man, and it may be conceived that fatty 
degeneration of its muscles may occur in some subjects and be- 
come a serious impediment to the performance of its functions. 

The mucous membrane of the tube is at its lower part quite 
thick, like that of the pharynx, of which it is an immediate con- 
tinuation. Its epithelium is ciliated, the motion being in the 
direction of the pharynx. This anatomical fact explains the 
intolerance which this membrane displays toward the injection 
of fluids from the pharyngeal orifice. The tube of the infant 
differs much from that of the adult. It is shorter, wider, and 
more nearly horizontal. 



Strieker's Hand-book, p. 073. 



216 



EUSTACHIAN TUBE. 



Riidinger divides the fissure of the tube into two portions. 
There is a semi-cylindrical space under the hook of the carti- 
lage which he calls the safety tube, and the fissure connecting 
with it the accessory fissure. 

Both divisions are produced by the shape of the cartilage, 
and are separated from each other by projections of mucous 
membrane. The mucous membrane is firmly attached to the 
tissues about it on the concavity of the hook • but at that point 
where the accessory fissures begin, fold-like projections are pro- 
duced between this fissure and the safety tube. The projection 




Fig. 76. — Transverse Section of Eustachian Tube and Surrounding Parts (after Riidinger). 
1, Median cartilaginous plate ; 2, lateral cartilaginous hook ; 3, dilator of the tube ; 4, lava, 
tor of the soft palate ; 5, basilar fibro-cartilage ; 6, 7, acinous glands ; 8, fat in the lateral 
wall; 9, safety tube; 10, accessory fissure ; 11, fold of mucous membrane; 12, adjacent tissues. 



of these folds prevents the safety tube from being closed. The 
closure is first possible at the point where the bend of the carti- 
lage becomes narrower, and the mucous membrane is not closely 
united with it. This point is at about the middle of the tube, 
where the mucous membrane has a slightly undulating surface, 
as seen in Fig. 78. 

The question whether the tube is normally open — that is, 
when the muscles of deglutition are at rest — is one which has 
been much debated. Throughout the narrowest part of the tube 



EUSTACHIAN TUBE. 



247 



the larger part of the outer and inner walls are in contact, but 
at the upper part is a small chink, which, as some authors 
claim, remains patent, while others deny this. However, any 
observer with normal tubes will be able to notice that the tube 
opens, or at least widens, at every act of swallowing. If the 
nostrils are tightly held, air will be pumped out of the tym- 
panum by the act of swallowing, and this air will be restored 
again to the ear-drum by swallowing with the nostrils free. 

MUSCLES OF THE TUBE. 

The muscular apparatus of the Eustachian tube also belongs 
to the pharynx. Indeed, these parts are so closely connected in 




Fig. 77.— Section of the Upper Third of the Eustachian Tube (after Riidiuger). 1, Me- 
dian cartilage; 2, lateral cartilage hook; 3, perichondrium; 4, submucosa; 5, insertion of 
the dilator of the tube ; 6, safety tube ; 7, lateral projection of the mucous membrane ; S. 
median projection of the mucous membrane ; 9, accessory fissure. 

all their structures, that an affection of one part independent of 
the other can hardly be said to occur. 
The muscles of the tube are— 



1. The Abductor or Dilator of the Tube.— This muscle 
is also known as the sphenosalpingo staphylinus muscle, the 



248 MUSCLES OF EUSTACHIAN TUBE. 

circumflexus palati, or tensor palati mollis. It is probably the 
most important muscle of the tube. 

This muscle arises from the sphenoid bone and the cartilage 
of the tube. It is inserted on the blunt edge of the cartilaginous 
plate along the whole length of the canal. It passes forward, 
inward, and downward, and its fibres spread out along the edge 
of the soft palate, and on the side of the pharynx. It enlarges 
the calibre of the tube by drawing the hook of the cartilage for- 
ward and a little downward. 




p IG . 78.— Section of the Middle Third of the Eustachian Tube (after Rudinger). 1, 2, 
Cartilage ; 3, dilator of the tube ; 4, folds of mucous membrane under the cartilage hook ; 5, 
folds of mucous membrane in the accessory fissure ; 6, submucosa. 

Rudinger confirms the view expressed by Von Troltsch and 
Mayer that the dilator of the tube passes directly into the tensor 
tympani muscle. This is true not only of the tendons, but also 
of the muscular fibres. 

Rudinger compares the rolling of the muscle about the ham- 
ular process of the pterygoid plate of the sphenoid, to the pulley 
arrangement of the superior oblique muscle of the eye. This 
attachment is certainly a point of fixation in the movements of 
the muscle. 



MUSCLES OF EUSTACHIAN TUBE. 249 

2. The Levator Veli Palati. — This muscle is not very in- 
timately connected with the tube, and yet it plays an important 
part in its mechanism. It arises with a cylindrical tendon on 
the lower surface of the temporal bone, on the anterior border 
of the entrance to the carotid canal, and by a few fibres from 
the cartilaginous portion of the tube. 

In the soft palate the muscles of the two sides are closely 
connected. From this point they separate, and each one runs 
upward, and is firmly attached, in the vicinity of the osseous 
tube, not only on the bone, but also to the cartilage and the 
mucous membrane of the tube. 

When this muscle contracts, by its becoming thicker, the 
membranous floor of the tube is pressed forward, and thus the 
long diameter of the tube is shortened, and the transverse di- 
ameter is enlarged, that is to say, it is made to gape very 
widely. 1 The salpingo-pharyngeus muscle also assists in this 
action. 

3. The Salpingo-pharyngeus (Rudinger).— This is a thin 
muscular layer, that passes from the lower end of the tube ob- 
liquely downward and backward, and is connected to the lower 
end of the median cartilaginous plate, and to the mucous mem- 
brane. It is inserted in the posterior wall of the pharynx. Ru- 
dinger considers this thin muscle to be a fixator of the median 
cartilaginous plate, in its various positions caused by the con- 
traction of the constrictor of the pharynx and the levator palati. 

The opening of the Eustachian tube is the result of a combi- 
nation of muscular action. If the three muscles are innervated 
simultaneously, and their contractions occur at the same time, 
the hook-shaped cartilage is fixed by the dilator of the tube and 
drawn outward, the concave portion of the tube becomes a little 
less curved, and the semi-cylindrical gutter is widened. If the 
levator of the velum contract, the space of the tube at the pha- 
ryngeal orifice is enlarged more than three lines. 

If the muscles cease to act, the elasticity of the cartilage 
comes into play, the canal becomes narrower, without being 
at its lower section completely closed, however." Respiratory 
movements of the membrana tympani have been often observed. 
and these occur through this gap in the tube, which cannot be 
said to be ever firmly closed. Any one who has often climbed 
high mountains and has become "out of breath" from exertion 
in reaching the top, must have observed in his own ears this 

'Rudinger: Beitrage zur vergleichenden Anntomio and Histologic dor Ohrtrom- 
pote. '•' Rudinger, Loo. oil, p. T. 



250 EISCOVEEY OF EUSTACHIAN TUBE. 

continuation of respiration through the tube. This fact throws 
light upon the etiology of cases of diseases of the middle ear, 
arising from inflammations of the respiratory organs, such as 
pneumonia and bronchitis. 



BLOOD-VESSELS. 

1. The ascending pharyngeal artery, from the external 
carotid. 

2. The internal maxillary, the larger of the two terminal 
branches of the external carotid, also supplies the Eustachian 
tube by its middle meningeal branch. 

3. Branches of the internal carotid artery. 

NERVES. 

1. The internal pterygoid, a branch of the third division of 
the fifth nerve, sends a supply to the dilator of the tube. 

2. The superior pharyngeal, a branch of the second division 
of the fifth nerve, sends branches to the pharyngeal orifice. 

3. The glossopharyngeal supplies the mucous membrane. 

4. The pneumogastric supplies the levator veli palati muscle. 

Historical. — The history of the successive steps by which the 
Eustachian tube, has taken its true and important position with 
relation to the study and treatment of aural disease, is a very 
interesting one, and has been very succinctly given by Dr. 
Ludwig Mayer, 1 from whose writings I have already quoted in 
the chapter on "Foreign Bodies." 

As has been said on page 4, Alcmeon and Aristotle knew of 
the Eustachian tube, but Eustachius was the first writer who 
gave an exact description of it. This is found in the edition of 
his anatomical works published in Venice in 1564. 2 

The passage in reference to the tube, as quoted by Mayer, is 
as follows : 

Ergo a caverna ossis lapidei, in qnarn meatus auditorius, conchion appellatus 
fmitur, via in nariuni cavitatem perforata est : ab ilia enim meatus alter oritur 
rotundo canaliculo similis, et instar tenuioris calami amplus, qui oblique ad 
interius interiusque basis capitis latus procedens, in medio quatuor foraminum, 
totum istud os penetrat atque perfodit. na posteriori ipsius sede arteria soporaria 
calvaria ingreditur : anteriori quartum nervorum cerebri jugum extra ipsam 
einergit : externum latus arterise in dura cerebri membrana distributee aditum 

1 Studien uber die Anatomie des Canalis Eustachii. Miinchen, 1866. 

2 Bartholorusei Eustachii Opuscula Auatoinica. 



EUSTACHIAN TUBE. 251 

patefacit : internum denique fissura qusedam circumscribit, quae a cuneum 
referentis ac lapidei ossis extremis partibus, oblique infra et anteductis, fit. 
Cseteruni hunc meatum, de quo sermo est, arbitrabitur fortasse quispiam eo loco 
desinere ; res autem non ita se habet, sed alterius generis substantia auctum, 
inter duos faucium seu guise musculos, a paucis hucusque bene cognitos secun- 
dum, paulo ante me moratae fissurse ductum ulterius procedit ; et juxta radicem 
intemse partis apophysis ossis alis vespertilionum similis in alteram narium 
cavitatem terminatur ; et in crassam palati tunicam prope radicem gargareonis 
inseritur. Substantia sane ejus, qua extrema fissurse ossi temporum et cuneo 
simili communis tangit, cartilaginea est ac admodum crassa ; huic vero appositse 
partis substantia exacta cartilago non est, sed membranosum nescio quid habet, 
et tenuior evadit a hujus meatus intena extremitas narium cavitatis medium 
respicies robusta est cartilago, quae plurimum extuberat, mucosaque ; narium 
tunica obducitur, ac fini ejusdem meatus quasi canitor prseferta esse videtur, 
figura teres non est, sed aliquantum depressa duos efficit angulos : latitudo 
cavitatis calamum, quo scribimus, fere adaequat, sed in fine duplo latior est, 
quam in principio, quae similiter mucosa sed tenui induitur tunica. Hoc calli- 
dissimum naturae artificium a me inventum contemni (ut opinor) non debet : 
siquidem turn philosophis, turn medicis non parum utilitatis aflerre potest, nam 
antiquiores philosophi, quorum numero, ut Aristoteles refert primo de natura 
animalium undecimo fuit Alcmeon, capras non modo ore ac naribus, verum etiam 
auribus quoque spirare, forte ob earn causam arbitrati sunt, quod meatum quam 
descripsi non ignorarent atque adeo saepius experti fuissent spiritum, ubi ipsurn 
quis cohibet, ad aurium cavitatem vi quadam impulsum recuiTere, et instar 
fluctus, auditus organa percutere. Erit etiam medicis hujus meatus cognitio, 
ad rectum medicamentorum usum maxime utilis, quod scient post hac ab auribus, 
non augustis foraminibus, sed amplissima via posse materias etiam crassas, vel a 
natura expelli, vel medicamentorum ope, quae masticatoria appellantur, com- 
mode expurgari. 

The last paragraph of this quotation shows, that Eustachius 
anticipated an earlier use of his discovery, than was made by the 
profession. 

The writers who followed Eustachius up to Valsalva's time, 
based their labors on what Eustachius had done. Mayer, in 
order to express his estimate as to their value, quotes Goethe, 
who says: " Denn eben wo Begriffe fehlen, da stellt em Wort 
zur rechten Zeit sich ein." Where an idea is wanting, a word 
can be put in its place. 

Valsalva, however, described the muscles of the Eustachian 
tube very exactly, but a hundred and twenty-five years after 
Eustachius. He supposed that the function of the muscles was 
to keep the tube constantly open. It was not until 1850 that the 
anatomical descriptions began to be accurate. Then F. Arnold. 
in his "Handbuch der Anatomic des Menschen," published at 
Freiburg in Bresgau, in 1851, gave a careful description of the 
tube. Merkel ("Anatomie und Physiologic der menschlicheii 
Stimme und des Sprech-Organs ") and Textual ("Xeuen U nter- 



252 PHYSIOLOGY OF MIDDLE EAR. 

suchungen fiber den Bau des menschlichen Schlundes und Kehl- 
kopfes "), 1861, afterward described the canal. Von Troltsch, 1 in 
an article published in his "Archives," elaborated the subject 
much farther. The labors of Mayer and Riidinger have brought 
our knowledge of the anatomical structure to the present stage. 
It should never be forgotten that Joseph Toynbee, was the 
first writer, in a paper presented to the Royal Society in 1851, to 
show that the faucial orifice was controlled by the muscles of 
the palate, and that the act of swallowing affected the calibre of 
the tube. Toynbee thought that the tube was completely closed 
in a state of repose, and although not strictly correct in this, his 
labors can hardly be overestimated. 

PHYSIOLOGY OF THE MIDDLE EAR. 

The waves of sound may reach the endolymph of the laby- 
rinth, through the bones of the skull. It is with difficulty, how- 
ever, that sonorous vibrations are transmitted from the air to 
solids and liquids. A special apparatus to secure their trans- 
mission is found in the middle ear, for, as we have seen, the 
external ear has a very small share in this function. 

Functions of the Membrana Tympani. 

The presence of the membrana tympani, in whole or in part, 
is not essential to fair hearing power. This was first clearly 
proven by Sir Astley Cooper, 2 in a case of which more will be 
found in the discussion upon paracentesis of the drum-head, in 
a subsequent chapter ; but, that it is very important to good 
hearing in some cases, is shown by the numerous instances in 
which an artificial membrana tympani raises the hearing power 
from a very low degree to a high one. The membrana tympani 
is perhaps more properly considered as the outer expansion of 
the ossicula auditus, for it is so intimately connected with the 
malleus, as to be essentially a part of the chain of bones that 
conducts sound to the endolymph of the labyrinth. Very great 
thickening of the drum-head, that is to say, of its fibrous and 
mucous layers, must of necessity involve the insertion of the 
malleus which is in its layers, so that we can hardly speak of 
the functions of the membrana tympani without including those 
of the ossicles. Yet there are a few points in its physiology 
that may be mentioned by themselves. Wollaston 3 snowed that 

1 Archiv fiir Ohrenheilkunde, Bd. I., Heft i., p. 15. 
? Philosophical Transactions, p. 155. 1800. 
*Ibid., p. 306. 1820. 



PHYSIOLOGY OF MIDDLE EAR. 2o3 

if the membrana tympani be rendered very tense, the ear is 
rendered insensible to low sounds, but those of a high pitch are 
made more intense. Blake 1 also found that in two cases of 
voluntary contraction of the tensor tympani muscle, the percep- 
tion increased from 3000 to 5000 vibrations during the contrac- 
tion of the muscle. Blake also showed that in a membrane 
slightly opaque and not very concave, but with a number of 
small calcareous deposits on a line with the lower end of the 
process of the malleus, the perception of high tones was greatly 
increased by an opening made in the drum-head. 

The peculiar formation of the membrana tympani, it being 
of the shape of a funnel with a depressed centre, surrounded by 
sides somewhat convex, make it, according to the physicists, 
peculiarly susceptible to sonorous vibrations, and it is easily 
thrown into corresponding movements when waves of sound 
enter the auditory canal and strike upon it. The membrana 
tympani probably has no fundamental tone of its own, or that 
tone has not been exactly determined. It is not thrown into 
vibrations by waves of a particular length more readily than by 
others. 2 Had the membrane its peculiar fundamental note, we 
should be distracted by its prominence in the ordinary sounds 
of life. Hensen 3 says, and has proven by experiment, that the 
membrana tympani is toned to a relatively deep note as the re- 
sult of its funnel-like shape. Hensen also states that perhaps 
the peculiar note of the drum-head, may be produced by blowing 
air into the auditory canal. This tone, he says, cannot be ex- 
actly determined, but it is certainly not higher than 700 vibra- 
tions. But, he adds, it is doubtful if a precise tone can be 
assigned to such an un symmetrical membrane. 

Seebeck and Mach, quoted by Hensen, 4 say that the regu- 
larity of our perception of tones is due to the deadening of 
sounds produced by the ossicles and the fluid of the labyrinth. 
It is probable that the membrana tympani can only be properly 
considered as a sound conductor in connection with the ossicles. 
It has one function entirely its own, however, which is of the 
highest importance. It is the protecting membrane of the tym- 
panic cavity, although its complete destruction or great thicken- 
ing of its layers, may not destroy the power of hearing. Even if 
a fair hearing of speech and music remain when it is removed, 
the tympanum is deprived of a covering which is essential to its 
continuation in health. As is seen in the study of chronic sup- 

1 Transactions of the American Otologieal Society, p. ??. 1873. 

2 M. Foster's Physiology, p. 575. ;; Hermann's Uandbuch. p. 40. 
4 Loc. cit. , p. 43. 



254 FUNCTIONS OF OSSICULA AUDITUS. 

purations of the middle ear, when the membrana tympani is 
destroyed or even partially removed, the tympanum is exposed 
to a series of dangers, any one of which may be destructive not 
only of the hearing but of the life. To preserve and quickly re- 
store an ulcerated membrana tympani, becomes therefore a very 
important duty. 

Ossicula Auditus. 

Many observations have been made upon the vibrations of 
the ossicula auditus by Politzer, Blake, Buck, Mach, Kessel, 
Hensen, Burnett, Helmholtz, and others. 1 

The action of the malleus and incus has excited considerable 
attention. Helmholtz 2 has shown, as has been already noticed, 
that when the malleus is carried inward, the incus also moves 
inward, and when the malleus returns to its position, the incus 
returns with it. Its saddle-shaped joint with cog-teeth permits 
this movement, while it prevents the stapes from being pulled 
back when the membrana tympani and the malleus are pushed 
out more than usual. The joint then separates, so that the mal- 
leus may be moved alone. The ligaments also serve to keep 
the malleus in place. The bones conduct vibrations as a single 
solid lever, the fulcrum of which is situated at the attachment 
by ligament of the short process of the incus to the posterior 
wall of the tympanum. 

Every movement of the membrana tympani is transferred 
through the ossicles to the membrane of the fenestra ovalis, and 
to the perilymph of the labyrinth. The vibrations are increased 
in intensity, but diminished in amplitude when they reach the 
perilymph. It is generally conceded that the ossicles have no 
independent vibrations that can be perceived, but that they act 
as a single solid body in conveying vibrations to the labyrinth. 

Tensor Tympani Muscle, 

Even when the tensor tympani muscle is not in action it is 
of use in preventing the drum-head from being pushed out too 
far. When it contracts the membrane becomes more tense. It 
has been supposed 3 to act either as a damper, lessening the vi- 
bration of the drum-head in the case of two powerful sounds, or 
as having an accommodative power in attuning the membrane 
to sounds which fall upon it. According to Hensen, 4 this action 

1 For a good digest of these see Hensen's article in Hermann, loc. cit. , p. 47 et seq. 

2 Die Tonenpfindungen, loc. cit. 3 Foster, loc. cit. 4 Loc. cit., p. 65. 



FUNCTIONS OF STAPEDIUS. 255 

is excited in a reflex way by the vibrations of the drum-head. 
The contraction of the tensor tympani is produced at will by 
some persons, and is accompanied by a crackling sound. 



Stapedius Muscle. 

The stapedius muscle is supposed to regulate the movements 
of the stapes, by preventing its foot-plate from being forced in 
upon the fenestra ovalis, during great or sudden movements of 
the drum-head. 

Lucae, quoted by Hensen, 1 found this contracted when the 
orbicularis palpebrarum muscle was strongly excited. He found 
with this a weakening of the power of hearing all musical notes, 
but an increase in the capacity of hearing those of 10,000 and 
more vibrations. 

Hensen, in one experiment carried a needle through the ten- 
don of the stapedius muscle. The point of the needle was in the 
facial nerve. As long as the tensor tympani was intact, the 
stapedius contracted energetically upon the reception of all 
tones, as Hensen believes in consequence of a mechanical move- 
ment of the ossicle produced by the tensor. When the tendon 
of the tensor was divided, the needle in the stapedius moved 
only upon the production of higher tones, from about 7000 vi- 
brations and upward. In lower tones, the movements were in- 
distinct, and the tones of the great and contra octaves did not 
produce any effect at all. 

Budge, quoted by Hensen, has attempted to show that the 
stapedius muscle is of importance in maintaining the equilib- 
rium of the body. 



Eustachian Tube. 

This passage serves to maintain an equilibrium of pressure 
between the external air and the tympanum, and as a means of 
exit of the secretions of that cavity. The physiology of the 
Eustachian tube has been most accurately studied by Toynbee 
and Politzer. It is to their studies and experiments, that we are 
indebted for that most valuable means of treatment, Politzer's 
method of inflating the middle ear. Politzer 3 concludes that — 

1. The tube is not constantly open. Its permeability varies 
in different persons. In some cases, even in quiet respiration, 
an interchange of air from the pharynx toward the tympanum 

1 Loc. cit. , p. 65. * Lehrlmeli, original, p. 77. 



256 functions or eustachian tube. 

takes place ; in others the act of swallowing or a powerful ex- 
piration becomes necessary. 

2. The tube is especially opened by the action of the muscles, 
during the action of swallowing, as shown by Toynbee and 
Politzer. 

3. A difference in the pressure of the air, is more easily 
equalized from the tympanum to the pharynx, than from the 
pharynx to the tympanum. 



CHAPTER X. 

Injuries of the Membrana Tympani. — Diseases of the Memhrana Tympani not Indepen- 
dent Affections. — Vascular, Nervous, and Lymphatic Supply, a Part of that of the 
Canal and Middle Ear. —Drum-head Subject to Injury by Explosions, Blows, and so 
forth. —Effects of Condensed Air. — Serious Injuries of the Head. — Fracture of the 
Handle of the Malleus. 

The diseases of the membrana tympani occur either as a result 
of an inflammation of the external auditory canal, or of the 
middle ear. I have not seen any cases of independent or primary 
myringitis, or inflammation of the drum membrane, such as are 
delineated with theoretical minuteness by some writers on otol- 
ogy. The anatomical structure of a membrane that has but one 
layer of tissue peculiar to itself, and that in its centre, but which 
is a direct uninterrupted continuation of the adjacent parts, pre- 
cludes the idea of an inflammation that occurs primarily in this 
part. There is probably no independent disease called myrin- 
gitis, in the sense that we speak of a keratitis or a retinitis. 

Dr. A. H. Buck ] has reported a case of interlamellar cyst of the membrana 
tympani, which might be supposed to be an independent disease of this part ; 
but the history shows that the patient was suffering, at the time of the formation 
of the cyst, from chronic eczema of the auditory canal, which renders it probable 
that the case was one of extension of disease of the canal to the drum-head. 

The vascular, nervous, and lymphatic supplies of the parti- 
tion wall between the auditory canal and the middle ear. belong 
also to those parts which it separates. Neither the integument- 
ary nor the mucous layer of the membrana tympani can be 
fully separated from it. These facts show that the drum-head 
has no independent existence. In the vast majority of instances 
the diseases of the membrana tympani are o\' a secondary char- 
acter. It is possible, however, that there may be a primary in- 
flammation of the membrana tympani in exceptional instances. 
for example, from a draught of air blowing upon the membrane. 
Yet, even in these cases, the inflammation, even it' it begins in 
the drum-head, advances so rapidly to the contiguous tissue, that 



1 Medioal Record, vol. vii., p 
17 



258 INJURIES OF MEMBEAXA TYMPANI. 

the inflammation becomes one of the middle ear almost in an 
instant. For these reasons, the term myringitis was discarded 
in the earlier editions of this work, and this example has been 
followed by most of the recent writers on aural medicine and 
surgery. Sir William Wilde, when using the term myringitis, 
did not mean an inflammation of the membrana tympani alone, 
but he used it to describe an inflammation of the middle ear, as 
careful reading of his work will show. 

Politzer, in his work upon the ear, so recently translated into 
English, describes a primary myringitis, occurring "after the 
action of a cold wind upon the ear, after a cold bath, after sea- 
bathing, or in the course of acute naso-pharyngeal catarrhs." 
He also describes the formation of one or more blisters of the 
size of a hemp-seed, and filled with serous fluid, as well as 
minute abscesses. He thinks, however, that the abscesses of 
the membrane described by Boeck, were secondary formations, 
occurring in the course of acute or chronic affections of the 
middle ear. After a careful consideration of the views of Po- 
litzer, and my own experience, I am still unconvinced that pri- 
mary myringitis is anything more than an extremely rare affec- 
tion. If indeed it occurs at all, I am doubtful. 

The membrana tympani is, however, subject to injury from 
explosions, or sudden and violent movements of the atmosphere, 
which cause the undulations to be condensed and forced inward 
upon the drum-head. It may also be ruptured by the force of 
condensed air, as, for example, that which is found in passing 
through the lock of a caisson used in excavating for the foun- 
dations of bridges, or the making of tunnels under rivers. The 
membrana tympani may also be ruptured by blows or falls upon 
the side of the head or upon the ear, or from direct injury by 
the striking of a sharp instrument directly upon the membrane. 
by violent sneezing or coughing, by the use of appliances for 
washing out the nostrils, and so forth. 

The explosion of artillery is not apt to cause rupture of the 
drum-head. When we consider the number of persons who 
have been thus exposed to injury, it is somewhat surprising that 
no more have suffered from this cause. After diligent inquiry 
among army surgeons. I have heard of but very few cases of 
rupture of the membrana tympani occurring from this cause ; 
and although I have seen many patients who became partially 
deaf from the exposures incident to campaigning, during our 
late civil war. I have as yet seen but one case, where a rupture 
of the drum membrane occurred from the explosion of artillery. 
The long-continued exposure to heavy firing often, and perhaps 
always, causes a temporary ringing in the ears, probably from 



RUPTURE OF MEMBRANA TYMPANI. 259 

concussion of the labyrinth, and sometimes hemorrhage from 
the vessels of the membrana tympani, but very rarely is a rup- 
ture produced. The effects of the concussion do not always pass 
away, and some soldiers acquire a chronic inflammation of the 
internal and middle ears from this cause, just as do boiler- 
makers, who work amid deafening noises. Ruptures from con- 
cussion do occur, however. I once saw a woman at the New 
York Eye and Ear Infirmary, who had suffered such an acci- 
dent from the firing of a pistol near her ear ; and Dr. Hackley 
observed a similar result in an actor who was obliged to fire a 
pistol over his shoulder during a play. The power of the mus- 
cles of the Eustachian tube, which act very quickly, and force, 
as it were, a current of air in upon the drum membrane from 
the inner side, is probably that which counterbalances the effect 
of a sudden condensation of air upon the outer side. The little 
chink, which normally exists in the calibre of the tube, is also a 
source of protection. Besides this, the structure of Shrapnell's 
membrane, made up as it is of fibres, much more loosely woven 
together than those of the remainder of the drum-head, assists 
it to yield to great shocks of sound. Those persons who suffer 
a rupture of the drum-head from external concussions, prob- 
ably have some catarrhal affection which prevents the air from 
freely circulating in the tubes and the cavity of the tympanum ; 
for we can scarcely believe that so few would suffer this acci- 
dent, were all drum membranes equally liable to it. During the 
heavy fighting of our civil war, infantry soldiers in the trenches 
were in the habit of lying down, while the artillery behind fired 
over their heads ; and yet, as I have found by inquiry, rupture 
of the membrana tympani was scarcely heard of. 

Gruber's experiments on the cadaver show that the resisting 
power of the membrane is very great. Dr. Schmidekam as- 
sisted Professor Gruber 1 in these experiments, which proved, 
according to the former author, that the resisting power of the 
membrane was greater in man than in the other animals. It 
required a column of quicksilver of 143 ctm. high to rupture the 
membrana tympani of an ear that had lain in alcohol for a few 
weeks. The stapes and incus had been removed. The rupture 
was straight and parallel to the lower three-fourths of the ante- 
rior line of attachment of the malleus. In another case a drum- 
head, which exhibited the remains of a former inflammatory 
process, in the form of a false membrane, was not ruptured 
until a column of quicksilver, 168 ctm. high, was used. Here 
again the rupture occurred on the anterior segment 



1 Lehrbuoh, p. 88d. 



260 RUPTURE OF MEMBRANA TYMPANI. 

Gruber also examined the resisting power of the drum-head 
by the following experiment : He introduced a catheter with a 
bulbous extremity into the Eustachian tube of a fresh subject, 
having a healthy membrana tympani, and fastened the catheter 
in the tube by means of a stout thread stuck through it. He 
then allowed a stream of air from a compression pump — air that 
had been condensed four or five fold — to pass suddenly into the 
tube, or after closing the tube by tying a cord about it, he 
stopped the external auditory canal by means of a gutta-percha 
plug, with a small tube in it, through which he allowed the 
compressed air to pass. Gruber was never able to break the 
membrane in this experiment. The gutta-percha plug with 
the tube was driven out of the canal, but the membrane was 
never ruptured. 

Professor Gruber saw a great many patients w T ho were en- 
gaged in the battles of Schleswig-Holstein and Bohemia in 1864 
and 1866, and although he examined nearly all the aural patients 
of the Garrison Hospital in Vienna, he saw but one where the 
explosion of projectiles had caused a rupture of the drum-head. 
In this case the soldier was knocked senseless by the explosion 
.of a grenade, which killed two near him. When he recovered 
his senses he was suffering from tinnitus aurium in the left ear, 
and was deaf on this side. Pain occurred, and in three weeks 
after, when he was seen by Dr. Gruber, he was found to have a 
roundish opening about one and a half line in diameter, in the 
anterior and inferior segment of the drum-head. The tubes were 
pervious, and there was no evidence that he had previously suf- 
fered from aural disease. This, however, was the only case 
among hundreds of soldiers that fought at Konigsgratz, who had 
suffered the injury which has been detailed. 

Dr. Andrew H. Smith, one of my colleagues at the Man- 
hattan Eye and Ear Hospital, was the medical officer in charge 
of the men engaged in laying the foundations for the bridge 
from New York to Brooklyn over the East River, and had many 
opportunities of observing the effects of compressed air upon the 
membrana tympani. Through Dr. Smith's courtesy, I saw some 
cases that illustrate this subject ; and I here give from Dr. Smith's 
notes, one of rupture of the membrana tympani which occurred 
while the patient was passing through "the lock." 

Dr. Smith describes the case of rupture of the membrane as 
follows : 

John H , on May 17th, the pressure being about 35 pounds to the square 

inch above the normal ; the patient was attacked while in the lock going down 
for the first time, by a severe pain in the right ear, followed by a slight discharge 
from the meatus. No sensation was felt as of anything giving way in the ear. 



EFFECTS OF CONDENSED AIR. 261 

He completed his watch, and then reported to me. On examination, the drum- 
head was found to be ruptured at its upper edge. The opening was nearly cir- 
cular and rather less than a line in diameter. The patient preferred not to go 
on with the work, and he was not seen by me again. 

Dr. Smith believes that most of the men who suffered from 
aural trouble after having been in the caisson, had previously 
some impairment of the permeability of the Eustachian tubes. 
The men under his care were "most strenuously" instructed not 
to enter the caisson unless they were able, when holding the nose 
and blowing forcibly, to feel the air enter both ears. Neverthe- 
less, cases occurred in which this precaution was neglected, and 
the individual was, in consequence, caught in the lock unable to 
"change his ears." 1 

Dr. Smith says that the structures within the tympanic cavity 
not being acted upon by the increased pressure, "are placed 
relatively in the same position as the skin under a cupping-glass," 
by the continued exposure to the effect of compressed air, when 
the Eustachian does not open, or rather, as we should say, when 
it does not act well, from swelling or thickening of its tissue. 
Then the intense congestion occurs, which may be followed by 
Inflammation, finally resulting in perforation of the membrane, 
as happened in one case reported by Dr. Smith in his paper. 

Politzer's method of inflating the ears was found very useful 
in treating these cases of simple congestion, which, if they had 
not been treated, would have resulted in tympanic inflammation 
and perforation of the drum-head. As an effect of the use of 
this method of treatment, many of Dr. Smith's men were en- 
abled to continue at their work who could not have otherwise 
done so without danger. The treatment became very popular 
among the men, so that as many as four or five of them would 
come at Dr. Smith's visit to have their " ears blown out." 

I saw three or four of these cases of congestion of the tym- 
panic cavity, they having been sent to me by Dr. Smith, and 
was enabled to see the great advantage of skilled medical advice 
to these men. Many ears would certainly have been perma- 
nently injured had not Politzer's method been employed at an 
early stage of the trouble. 2 

1 This is the term used by the men to signify the operation of holding the nose and 
blowing until the air is felt to enter the middle ear. This operation has to be con- 
stantly repeated while the air pressure is increasing in the look, in order to relieve the 
pain resulting from the pressure upon the membrana tympani. In some persons the 
act of swallowing answers equally well. 

. '•'Dr. Smith's paper on "The Effects oi' High Atmospheric Pressure, including the 
Caisson Disease," received the prize of the Alumni Association of the College of Physi- 
cians and Surgeons for 1873. My extracts were taken from the manuscript loaned to 
me by the author. 



262 EFFECTS OF CONDENSED AIR. 

A gentleman who once consulted me in reference to what I 
deemed to be an incurable chronic catarrh of the middle ear, 
which had resulted in thickening and sinking of the drum-head, 
afterward came to me with a perforation of the membrane of 
one side and discharge of pus from the tympanum, which he 
stated was caused by a visit to the caisson. The perforation 
soon healed, and the hearing was rather worse than before the 
accident. 

Dr. John Green, 1 of St. Louis, had previously to Dr. Smith 
made some observations upon ''the physiology of the Eustachian 
tube, during a short exposure to an atmospheric pressure of sixty 
pounds to the square inch." Dr. Green's observations were made 
while bridge-piers were being sunk to the rock underlying the 
bed of the Mississippi Eiver at St. Louis in 1809-70. 

The entrance to the chamber of condensed air was "through 
an air-lock, or small chamber into which the condensed air 
could be admitted gradually, occupying, for the higher degrees 
of pressure, from four to ten minutes." The exit occupied about 
the same time. 

The accidents to the ears occurred, as in Dr. Smith's cases, 
while passing through this lock. Sudden chilling of the body 
from changes in temperature in the chamber were, according to 
Dr. Green, causes of catarrhs. This theory is rather more suffi- 
cient to explain the cases of tympanic congestion when the tube 
was not completely pervious, than the one of mechanical press- 
ure, although undoubtedly both causes acted together in pro- 
ducing aural affections. 

Dr. Green notices an interesting phenomenon observed in 
coming out of the lock, which Dr. Smith also observed. There 
was a spontaneous escape of air through the Eustachian tubes 
in a succession of puffs, succeeding each other at intervals of 
fifteen or twenty seconds, independently of respiration, and ab- 
solutely without the concurrence of any muscular action. The 
phenomenon suggested to Dr. Green "the action of a lightly 
resisting valve, necessitating a slight but perceptive increase of 
pressure within the tympanic cavity, to open the passage to the 
pharynx." Dr. Green observed several cases of rupture of the 
drum-head and acute catarrh occurring as a result of the unequal 
pressure, and of the exposure to an uneven temperature. 

Dr. A. Magnus, 2 of Konigsberg, investigated very carefully 
the behavior of the ear in condensed air, in 1863, while a rail- 
way bridge was building in his city. He proved that the injury 

1 Transactions of the Americau Otological Society, 1870. 
9 Archiv fur Olirenheilkunde, Bd. I., p. 270. 



EFFECTS OF CONDENSED AIPw 263 

to the ear was caused by pressure upon the membrana tympani, 
because when he plugged the auditory canal hermetically, no 
unpleasant sensations were felt, but when he removed the stop- 
per the air streamed with a powerful current into the canal, and 
pain occurred very soon. The ear that was stopped remained 
without pain, and the Valsalvian experiment soon relieved the 
pain in the uncovered one. Magnus also proved by an exam- 
ination of ears when the pressure was being exerted, that the 
membrana tympani was actually pressed inward. The triangu- 
lar spot was obliterated when the pressure was greatest and the 
pain severe. A patient without any membrana tympani, who 
was subjected to the condensed air, had no pain. Indeed, there 
was not a trace of an unpleasant sensation. 

The membrana tympani undoubtedly owes much of its re- 
sisting power, as Mr. Shrapnell pointed out, to the existence of 
a triangular membrane at its upper portion that is less tense 
and thick than the remainder of its structure, the so-called mem- 
brana flaccida, or ShrapnelPs membrane, which yields when 
undue pressure is brought upon it. The membrane has, per- 
haps, some additional defence in its oblique position in the 
canal, which causes a portion of it to be covered by the walls in 
such a way as not to receive the whole force of* the column of 
compressed air. * 

The membrana tympani is perhaps more frequently injured 
by mechanical violence to the head or to the membrane itself. 
Professor Eobert F. Weir, 2 formerly surgeon to the New York 
Eye and Ear Infirmary, has seen four such cases. In one the 
drum-head was ruptured by a blow upon the head with the hand. 
In another, fragments of rock from a blast struck the head and 
ruptured the membrane. In the third case the injury was caused 
by a snow-ball striking the ear; and in the fourth a hair pin was 
accidentally forced through the part. In the first three of Dr. 
Weir's cases the rupture was slit-shaped, parallel and posterior 
to the handle of the malleus. 

I have now under my observation a gentleman of about fifty 
years of age, whose membrana tympani is said to have boon 
ruptured when he was a small boy, by blows upon the side of 
his head, given by one of his teachers. The membrane is nearly 
entirely gone, and there is at times a purulent discharge from 
the tympanic cavity. Teachers and parents who have the bad 
habit of striking children unexpectedly to their Little charges, 

1 The effects of compressed air upon the bearing power will be again alluded to in 
the chapter on "Chronic Non-suppurative Inflammation." 

2 Verbal communication. 



264 INJURIES OF 3IEMBRANA TYMPANI. 

should be warned of the danger of a box on the ear to the in- 
tegrity of the organ. 

The membrana tympani is sometimes ruptured in attempts 
to remove foreign bodies, such as inspissated cerumen, and so 
on, by means of a probe, as has been seen in one of the preced- 
ing chapters. The text-books of Toynbee and Von Troltsch 
record several interesting cases of injury to the drum-head by 
mechanical violence. The latter author relates one in which a 
young man, while going up a ladder, accidentally struck his ear 
against a blade of straw, which passed through the membrane 
and caused the severest pain, so that he nearly fainted. In one 
of Toynbee's * cases the rupture was caused by an unexpected 
blow upon the ear of a boy by a tutor. In another case the ear 
was hit by a bolster while the boys were engaged in a playful 
contest. In both of these cases the rent was found to be on the 
lower part of the membrane. 

Toynbee also relates a case which is of interest on account 
of the nervous symptoms produced by it. A young man of 
seventeen, while shooting, in endeavoring to force his way 
through a hedge, got a twig into the right auditory canal. It 
produced sudden and severe pain, followed by bleeding. Mr. 
Toynbee saw trie patient a week afterward. The pain speedily 
subsided ; but for days after the accident there was "a feeling 
on the same side of the tongue as if something cold had been 
rubbed over it ; the taste on that side also was impaired." The 
sensibility of the tongue to touch was, however, unimpaired. 

The chorda tympani nerve was probably injured in this case ; 
for the same sensations are sometimes caused when a bit of 
cotton-wool is brought in contact with the cavity of the tympa- 
num and with the nerve. 

I lately saw a man of thirty-eight years of age, who stated 
that at sixteen, he ruptured the right drum-head in the following 
manner : While in the woods engaged in securing sap for mak- 
ing maple sugar, he bent down over some underbrush, so that 
a twig entered the auditory canal. Immediately "he felt as 
if half his tongue were paralyzed." He does not remember 
whether the ear bled or not, whether there was any pain or 
suppuration from it, but he does remember the loss of sensation 
in half his tongue. He has never heard with the ear since the 
accident. He has chronic inflammation of the left ear. There 
is no aerial conduction whatever on the right side. There is a 
distinct opacity in front of the handle of the malleus. 

This patient is a highly educated man. While there are sev- 

1 Text-book, p. 28. 



RUPTURE OF MEMBRANA TYMPANI. 263 

eral negative points in the history, since he cannot remember 
whether he had pain, or bleeding, or suppuration from the ear, 
there is enough that is positive in the history and in the appear- 
ances to enable us to believe that this is a case of rupture of the 
membrane, followed by proliferous inflammation of the tym- 
panum. Since the patient has a chronic inflammation of the 
middle ear of the uninjured side, we may believe that we can- 
not ascribe all the morbid changes in the tympanum to the in- 
jury of the drum-head, unless we suppose that there may be a 
sympathetic inflammation of the middle ear, just as there is a 
sympathetic inflammation of the uveal tract of the eye. This 
supposition is not wholly groundless, although as yet appar- 
ently having only an analogical foundation. Sympathetic in- 
flammation of the eye usually, if not always, has its origin in 
the uveal tract, and involves the muscle of accommodation ; 
why may not a traumatic inflammation of one ear, especially 
an injury of the ossicles and middle ear, produce a sympathetic, 
plastic inflammation of its fellow ? 

The case is inserted here, chiefly to show the effect of an in- 
jury to the chorda tympani nerve. In thinking it over, how- 
ever, the possibility of a sympathetic otitis has occurred to me. 
Reasoning from analogy, it is possible to suppose such a condi- 
tion of things. 

The function of the chorda tympani is probably chiefly in connection with 
that of taste, and not of hearing. 

Professor Flint * relates a case which sustains this view. A soldier received 
a gunshot wound, the ball passing through the head, entering just above the ala 
of the nose, on the left side, and emerging behind the mastoid process of the 
right temporal bone. The wound healed, with the usual symptoms of complete 
facial paralysis on the right side. The buccinator and orbicularis oculi were 
completely paralyzed. The hearing was perfect. The sense of taste was entirely 
abolished in the anterior portion of the tongue on the right side. These facts 
were verified by Professor Dalton, of this city. 

Experiments upon dogs and cats, and other animals, also show, according to 
Flint, that the chorda tympani influences taste ; for sections of the root of the 
fifth pair, or of the chorda tympani, is followed by loss of taste in the anterior 
portion of the tongue. 

The chorda tympani is given off from the facial, as it passes vertically down- 
ward at the back of the tympanum, about a quarter of an inch before its exit 
from the stylo-mastoid foramen. It ascends from below upward in a distinct 
canal, parallel with the aqueduct of Fallopius, and enters the cavity of the tym- 
panum through an opening between the base of the pyramid and the attachment 
of the membrana tympani. It becomes covered by mucous membrane, and 
passes forward through the tympanic cavity between the handle of the malleus 
and the vertical cms of the incus (see Fig. 44, on \>. L94), and then passes out 



1 The Physiology of Man, The Nervous System, p. 157, 



266 euptuPwE or membkaxa tympani. 

of the cavity, through the canal of Hugier, at the inner side of the Glaserian 
fissure. It then passes downward, between the two pterygoid muscles, and 
meets the gustatory nerve at an acute angle, and communicating with this it 
passes to the submaxillary gland; after joining the submaxillary ganglion it ter- 
minates in the lingualis muscle. 

Its anatomy seems to indicate that it has very little to do with the function 
of hearing. It merely passes through the tympanum, without supplying any of 
its tissues, as has already been described in the chapter on the anatomy of the 
middle ear. 

Claude Bernard also performed experiments upon the chorda tympani of cats 
and Albino rats, by cutting out the facial nerve at its exit from the stylo-mastoid 
foramen. In from six to ten days the terminal twigs of the lingualis nerve, and 
the nerve-fibres coming from the chorda tympani were found to have undergone 
fatty degeneration. Degenerated nerve-fibres were also found in the tip of the 
tongue, but not in the papillae. There were also degenerated nerve-fibres in the 
submucous tissue. 1 

Severe vomiting sometimes causes a rupture of the drum- 
head, as does strangulation by hanging. The cases of rupture 
that occur during whooping-cough, and sneezing or blowing the 
nose, are not properly to be considered in the present chapter ; 
for when the membrana tympani is ruptured in such cases, 
there is usually, if not always, some pre-existing catarrh of the 
Eustachian tube and tympanic cavity. I have seen several such 
cases, but in all of them I have been able to trace disease of the 
middle ear as having preceded the breaking of the drum-head. 
The great accumulation of mucus caused by the catarrhal in- 
flammation will be very apt to cause a rupture by mechanical 
pressure from within upon a distended mucous membrane and 
fibrous layer, unless the cavity be emptied by means of the 
catheter or Politzer s method. 

In countries where punishment is meted out in exact pro- 
portion to the amount of personal injury done to the person 
assaulted, blows upon the side of the head which result in rup- 
ture of the membrana tympani are made the subject of careful 
medico-legal examination. 2 

In order to determine the cause of a rupture of the membrana 
tympani, it must be seen within a few hours of the injury ; for 
suppuration may occur soon after it has occurred, when it will 
be impossible to decide whether it had a traumatic or spontane- 
ous origin. 

1 Monatsschrift fur Ohrenheilkunde, No. 1, 1873, from Comptes Rendus, Hebdom. 
des Seances de l'Academie des Sciences, T. lxxv., No. 27. Paris, 1872. 

- According to the Austrian criminal code, an injury is defined to be a severe one, 
when the person suffering it is deprived of his usual health, or kept from his occupa- 
tion for a period of not less than twenty days. — Politzer, Wiener Med. Wochenschrift, 
Nos. 35, 36, 1872. 



BUPTURE OF MEMBEANA TYMPANI. 26? 

A traumatic rupture of the membrana tympani, especially 
one arising from the perforation of the membrane by a sharp 
instrument, is much more apt to cicatrize promptly, without 
suppuration, than one that has been perforated in the course of 
inflammation of the middle ear. 

The force of large waves upon the side of the head in sea- 
bathing, is an occasional cause of rupture of the membrana 
tympani. I have seen such cases, and one where both mem- 
branes were ruptured. A wave is sometimes allowed to strike 
upon the membrane with great violence, and if it do not break 
it, it will at least excite an inflammatory action. Physicians 
who practice at the sea-side, should warn their patients of this 
danger from surf -bathing. Long Branch and Newport, furnish 
every year a certain contingent of aural patients from this cause. 

A little care so that the waves do not strike the side of the 
head in full force, and plugging the meatus lightly with cot- 
ton, will be found to be a sufficient protection from the sever- 
ity of the waves. If water be allowed to stay in the auditory 
canal for some time, it becomes a source of congestion ; but 
such causes of diseases of the middle ear are more appropriately 
considered in a subsequent chapter. 

Dr. C. H. Burnett, 1 of Philadelphia, has reported a case of 
evulsion of the membrana tympani, from the splashing of mud 
into the ear by a horse while the patient was crossing the street. 
The patient was thirty-nine years old, and consulted Dr. Burnett 
three days after the accident. He stated that his ear was sound 
until the mud came into it. Upon returning to his shop — he was 
a machinist — he was examined by some of his comrades, who 
said they saw foreign objects in the meatus, which they pro- 
ceeded to extract with chips and mechanics' small tools. Several 
"little white pebbles" were taken out, which were probably the 
ossicles. Great impairment of the hearing of the ear followed. 
The patient was very pale, anxious and bathed in cold perspira- 
tion when he visited Dr. Burnett. A watch that should have 
been heard 40 feet was only heard 5 ctm. The tuning-fork placed 
on the vortex was heard very distinctly in the injured ear. 

On examination, Dr. Burnett found the meatus uninjured. A 
small piece of mud was adherent to the antero-superior quadrant 
of the periphery of the membrana tympani. The membrane was 
entirely destroyed, except a very narrow border. There were no 
ossicles visible. The inner wall of the tympanum was fully ox- 
posed to view. The mucous membrane was healthy, but slightly 
abraded on the promontory. Twenty days after, without treat- 



1 Transactions of the American Otolosrical Society, 1S70. 



268 EUPTUEE OF MEMBEAXA TYMPANE 

merit, patient was free from pain and "ruddy and cheerful. " 
The border of the membrana tympani had become adherent to 
the promontory. Of course the hearing power was not improved, 
thanks to the care of his surgical comrade, who so carefully 
removed the "white pebbles" from his ear. 

Dr. J. Orne Green ' reports a case where the explosion of a 
bag of gas near the ear caused a rupture of the membrana 
tympani. The patient, who was preparing for an exhibition in 
which an oxy-hydrogen light was to be used, was standing a 
few feet from the bag, and with his left side toward it at the 
time of the explosion. The immediate effect was some slight 
confusion of intellect, which soon passed off ; but the next day 
the left ear began to be painful, and on blowing the nose, air 
whistled through it. 

Dr. Green saw the patient twelve days after the accident, 
and found the membrana tympani red and swollen, and on the 
posterior segment just behind the umbo, a rupture 1J line long, 
nearly perpendicular, through which purulent matter could be 
forced by Valsalva's method of inflation. H. D., -£%. 

Dr. Green states that this patient had previously suffered 
from impaired hearing and mucous rales in his ears. Most of 
the cases of rupture of the drum-head on record, if the ante- 
cedents had been inquired into, would undoubtedly exhibit the 
same condition of things. 

The assistant of the patient whose case has just been quoted, 
suffered at the same time from the explosion of a bag of gas, 
and also received rupture of the membrane, which resulted in a. 
purulent inflammation of the tympanic cavity. He was treated 
by Dr. Henry L. Shaw, of Boston. In both of these cases the 
rupture healed perfectly, and the hearing power was partially 
restored. In Dr. Green's case it became J£. 

Dr. Green saw two other cases in which the patients suffered 
from the concussion of the same accident. It caused a loud 
buzzing in the ear and confusion in the head. The patients 
consulted Dr. Green on account of the tinnitus which was caused 
in one case, but aggravated in the other, for the latter patient 
had previously suffered from disease of the middle ear. 2 

If a person be a sufferer from catarrh of the middle ears, the 
drum-head, as has been already intimated, is much more likely 
to be ruptured by blows, falls, exposure to the surf in bathing, 

1 Transactions of the American Otological Society, 1872. 

' 2 Dr. Green records several other cases of injury of the side of the head which pro- 
duced a rupture of the membrana tympani, but as they do not differ from others that 
aTe noticed in this chapter, I beg to refer my readers who may wish to carry this sub- 
ject farther, to his interesting paper. 



KUPTURE OF MEMBRANA TYMPANI. 260 

or the like. In fact, I am inclined to doubt if persons with well 
ventilated tympanic cavities, and normally acting drum-heads 
ever suffer a rupture of the membrana tympani, except from 
very great direct violence. 

In 1875 I saw a little boy who was thrown from his pony a 
few hours before he consulted me. He struck upon his right 
side, and he had a free discharge from his right ear immediately 
afterward. His hearing distance was ¥ V when examined, and 
he heard the tuning-fork better on the injured side. Blood was 
found on the walls of the auditory canal, and the membrana 
tympani was ruptured in the centre. The ear was let alone very 
carefully, and the drum-head soon healed. There remained, 
however, a depression in the centre at the site of the rupture. 
This little fellow had nasal and pharyngeal catarrh at the time 
he received the fall, or I suppose it is not likely that the mem- 
brana tympani would have ruptured from what was a slight 
injury, for he fell upon the lawn of a country place, and from 
a very small pony. At any rate, in spite of the best of care from 
his family and from a distinguished expert in aural disease, with 
whom I have occasionally seen him professionally, he has gone 
on with a catarrhal or proliferous inflammation in the middle 
ears, until now, as he is growing into manhood, his hearing is 
very much impaired. 

I once saw a case of hemorrhage from the auditory canal in 
a boy of three and a half years, who fell from a rocking-horse. 
He had had a discharge from the same ear a year before which 
had ceased. Some hard wax and a large blood-clot were re- 
moved from the auditory canal, but the membrana tympani was 
uninjured and looked natural. 

In 1881 a young gentleman of nineteen consulted me in re- 
gard to an injury to his left ear, of which he gave the following 
account : Two days before it was hit by the flat surface of a 
boxing-glove in the hands of his antagonist. He became dizzy 
and felt a sense of pressure upon the ear. He did nothing to 
relieve these symptoms and they passed away. But on consult- 
ing me, he states that he has now a feeling of tightness and 
pain in the ear, and noise causes discomfort. He once had a 
discharge from the ear after scarlet fever. His hearing dis- 
tance is j\ on the injured side. £-§ on the other. The tuning-fork 
is heard better in the affected ear. There is a red line through 
the anterior segment of the membrane, beginning at the end of 
the malleus. The ear was inflated by Politzer's method, and 
this was repeated every few days. The patient was also ad- 
vised to wear cotton in the meatus o( that side. The ear grad- 
ually recovered its normal sensations. 



270 RUPTURE OF MEMBRAXA TIMPANI. 

Here, again, we had to do with an ear that was probably not 
entirely sound when the accident occurred. It is probable, from 
the history, that the drum-head was at one time injured by 
ulceration, and that it was a cicatricial membrane when the 
canal was struck. 

In the following case the drum-head was so badly injured by 
direct violence, that it will never be a perfect membrane : 

F. N , aged forty-one years. Five days ago his infant child, while he was 

playing with it, pushed a button-hook into the right auditory canal. A momen- 
tary pain occurred, attended by bleeding. The patient's wife washed out the 
ear, and great pain followed. Since then the pain has diminished, and he has a 
purulent discharge from the ear. He never had a disease of the ear before, as 
far as he knows. The hearing distance is K. E., - 4 a « ; L. E., |g. The tuning-fork 
placed on the vertex is heard better in the right ear. The bone conduction is 
better than the aerial on the right side. The upper wall of the osseous canal is 
red and swelled. Pus lies upon the right drum-head. It is red in the periphery 
and along the handle of the malleus. It is perforate in the inferior and the pos- 
terior quadrant. The left membrana tympani is opaque and neoplastic. The patient 
was treated for two months. The suppuration nearly ceased. He had no pain, 
and slight tinnitus, when I last saw him, but the perforation in the drum-head 
remained. 

Although this patient had no recollection of ever having had 
a disease of his ears, I am sure, he must have one day had some 
affection of his uninjured ear. The impairment of hearing (}•§), 
and the neoplastic drum membrane cause me to believe this. 
He may also have suffered in his right ear, so that it may have 
been more susceptible to injury than a normal drum-head. Yet 
it must be admitted, that a thrust with a button-hook is capable 
of rupturing a drum-head whose tissue has never been injured 
by ulceration. 

At a recent meeting of the New York Ophthalmological So- 
ciety, Dr. Loring reported a case of rupture of the drum-head on 
each side, with bleeding, from a fall upon the forehead upon the 
fender. The patient was a child, and the strictest inquiry, ac- 
cording to Dr. Loring. failed to elicit the history of catarrh of 
the nares or middle ears. 

In this case the rupture occurred, as Dr. Loring thinks, from 
contre-coup, the ears not being directly affected by the fall, but 
the full force came upon the region of the frontal sinus. The 
child, according to the statement of Loring, has since suffered 
at times from aural catarrh. 

Very severe injuries of the head, such as those suffered by 
laborers falling from scaffoldings used in building, or by being 
hit by "falling planks" (Buck), falls, gun-shot wounds in the 



FRACTURE OF TEMPORAL BONE. 271 

auditory canal, serious beatings or pummellings upon the head, 
especially over the temporal bone, may produce fractures of the 
temporal bone, as well as other bones of the skull. Bleeding 
from the ear, or a serous discharge from the ear, are among the 
prominent symptoms of such an injury. These cases are usu- 
ally seen by general surgeons, who do not give the ear a critical 
examination in determining the nature and extent of the in- 
juries. It was formerly supposed 1 that a severe and long-con- 
tinued bleeding from the ear was positive proof of a lesion of one 
of the sinuses. But as Buck 2 has shown, a bleeding from the 
tympanic artery may cause this, without necessarily involving 
the sinuses. When an injury to the head is followed by bleed- 
ing from the ear, even if it be trivial, we may, as stated by Buck, 
diagnosticate a fracture of the temporal bone in the vicinity of 
Shrapnell's membrane, and probably in the line of the Glaserian 
fissure, but we cannot state that a deeper and a more extensive 
injury has occurred. A fracture of the temporal bone may occur, 
however, without hemorrhage from the ear. Buck quotes a case 
from Dr. Geo. L. Peabody, which proves this. A man fell twenty 
feet from a scaffolding, striking his head upon the pavement. 
He died two days after the injury. There was no evidence of 
fracture of the bones of the skull. " There was a thin watery 
discharge from the nose, but there were no aural signs except 
deafness. " There were several fractures of the skull. There 
was one on the right side extending from the foramen lacerum 
posterium through the middle of the petrous portion of the tem- 
poral bone, and terminating in the roof of the tympanic cavity. 
The ossicles were found imbedded in a clot of blood. There was 
no blood in the mastoid cells. On the other side, there was a 
more extensive fracture of the same parts with a clot around the 
ossicles and also in the mastoid cells. The fracture extended 
into the semi-circular canals of both sides, and the right cochlea 
contained a clot. 

It is certain also, that patients recover from fractures of the 
tympanic portion of the temporal bone. A prominent physician 
of a neighboring city was attacked by ruffians one night, a few 
years since, and severely beaten over the head, so that he was 
unconscious for a short time. A large hemorrhage occurred 
from one ear, but he recovered perfectly, except that his hearing 
power was nearly destroyed upon that side. The membrana 
tympani a few months after the injury was without a cicatrix 
or other evidence of a rupture, as I found on examination. 1 

1 Prescott Hewitt in Holmes 1 Surgery, vol. ii., p. c:s. Edition of 1861. 

- Diseases of the Ear, p. 278 et seq. 8 Loo. oil . p. 29. 



272 HEMORRHAGE FROM TYMPANUM. 

This gentleman having died some year or so after the injury, 
it was supposed by some that his death resulted from it. But I 
have very good authority for stating that he died from chronic 
renal disease. 

Dr. J. D. Rushmore, surgeon to the Brooklyn Eye and Ear Hos- 
pital, also reports ' with great care a case bearing on this subject. 
A man of sixty-eight years, after a peculiar and uncomfortable 
feeling in his head for a few minutes, fell backward and toward 
the left side, and lost in a few minutes, by the estimate of a physi- 
cian, about sixteen ounces of venous blood from his left auditory 
canal. He became unconscious for a few hours, and complained 
of headache and vertigo. The man had been a busy but well 
man. There was no renal disease. Dr. Rushmore saw the patient 
four days after the injury. There was then tenderness around 
the left auricle and dulness of hearing on that side. There was 
slight oedema of the mastoid and a narrow ecchymotic spot ex- 
tending toward the styloid process. The auricle was hyper- 
aemic. A soft clot filled the canal, and this was swollen and 
tender after the clot was removed. There was no hemorrhage 
and no serous discharge. Hearing distance for the watch, ; 
tuning-fork better through the bones, and it was heard better 
on the sound side. The drum-head could not be seen. The 
ear was treated by cleansing, leeches to the mastoid, oleate of 
morphia in front and behind the auricle. Sleeplessness was re- 
lieved by opium, bromide of potash, and alcohol. The result 
was that the patient finally heard the watch in contact with the 
ear, and the voice fifteen feet. The bone conduction remains bet- 
ter than aerial. In all respects, except the dulness of hearing, 
the patient, ten months after the injury, was as well as before he 
received it. When the membrana tympani was first seen, fully 
six weeks after the injury, there was a red irregular line, broad 
on the periphery, and narrowing toward the centre of the mem- 
brane, extending from the apex of the light spot to the end of 
the handle of the malleus. Five days after, the red line had 
nearly disappeared, and the light spot began to be mapped out. 
There was a purulent discharge from the ear for sixteen days 
after the injury. 

Dr. Rushmore concludes, that there was a fracture beginning 
in the external auditory canal, and extending downward and 
forward. The origin of the bleeding he is at a loss to explain. 
I think there is no reasonable doubt, however, that it was fron\ 
the vessels of the tympanic cavity. 

The tuning-fork located the situation of the hemorrhage. 

1 Archives of Otology, vol. ix. 



HEMORRHAGE FROM TYMPANUM. 273 

Had there been a hemorrhage into the labyrinth, the bone 
conduction would not have been better than the aerial. A 
careful examination of an osseous specimen will convince any 
one of the possibility of rupturing the tympanic vessels only, 
by such a fall. The healing of the membrana tympani with 
scarcely a trace of the rupture, explains those cases of re- 
ported bleeding from the ear, when the drum-head shows no 
cicatrix in a few weeks after. That such a perfect healing may 
occur, I have been able to demonstrate on several cases. 

A profuse watery discharge from the ear, occurring immedi- 
ately after the injury, is good evidence of a fracture of the pe- 
trous portion of the temporal bone, but a watery discharge may 
set in a short time after the accident, and be merely inflamma- 
tory in character and by no means be the cerebro-spinal fluid, 
even though it be excessive. The facial canal and the motor 
filaments of the fifth nerve may be injured in fracture of the 
temporal bone, and paralysis occur. 

Our knowledge of these cases would be greatly increased, if 
a careful examination of the membrana tympani were made in 
each case of supposed fracture of the base of the skull. 

Prognosis. — The prognosis of a fracture of the temporal bone 
with rupture of the membrana tympani is by no means unfavor- 
able, except as regards an impairment of the hearing, as is seen 
by the illustrative cases. But each case must be considered by 
itself. ISTo general prognosis can be made. 

The prognosis in a case of rupture of the membrana tympani 
depends very much upon the nature of the injury that caused it. 
An accident of this kind, when produced by the concussion of a 
heavy explosion or of a severe blow upon the side of the head. 
is much more serious in its nature than an injury to a drum- 
head from the forcing through it of any sharp body, such as a 
knitting-needle, pen-holder, twig of a tree, a blade of straw, or 
the like. The former class of injuries are apt to produce a frac- 
ture of the temporal bone, a concussion of the labyrinth, or a 
fracture or dislocation of the ossicula, as well as a rupture of 
the drum-head. Such a result, at once takes the affection away 
from the category of simple injuries, and renders it a very seri- 
ous one, not only with reference to the hearing power, but also 
as regards life. The tuning-fork becomes a valuaMe assistant 
to diagnosis in cases of rupture. Its vibrations will be heard 
more distinctly in the injured ear than the other, and the bone 
conduction will be better than the aerial, if the labyrinth be not 
injured. A simple rupture usually heals in a few days without 
great injury to the hearing. A suppurative process may result, 

18 



274 EUPTURE OF MEMBRANA TYMPANI. 

however, and become chronic, when the treatment should be 
the same as that of any other similar affection arising spon- 
taneously. 

Treatment. — We can do very little indeed in the way of 
treatment, if no inflammatory symptoms, such as pain or swell- 
ing-, occur. Above all, we should not disturb the ear imme- 
diately after the occurrence of the injury, as is sometimes 
mistakenly done, by syringing it. There is a very prevalent 
disposition in the profession, to syringe the ear in every case of 
aural disease that presents itself ; but no ear should be syringed 
without a good and sufficient reason. 

A large clot in the canal should be removed with gentleness 
and care, but syringing the ear immediately after a minute 
hemorrhage from a superficial injury is bad practice. Union 
by first intention, is favored by letting the drum-head absolutely 
alone. It is meddlesome surgery to do very much to such cases. 

When inflammatory symptoms occur, they should be met by 
leeches, the warm douche, and by the other means that will be 
detailed in the chapters on "Acute Inflammation of the Middle 
Ear." Meanwhile the ear should be protected from the cold air 
by a bit of cotton placed in the meatus, and the patient should 
be kept under careful but not meddlesome observation. 



Fracture of the Handle of the Malleus. 

This rare accident has been described by Meniere, Von 
Troltsch, and Weir. 1 The history of the case of the second- 
named author is as follows : A man accidentally thrust a pen- 
handle which he held in his hand into his ear, in consequence 
of knocking his elbow against a door. The severe pain caused 
him to faint. After he recovered, he found that he heard badly 
from the injured ear, and he suffered from tinnitus of that side. 
Von Troltsch saw the case a year after, and from the peculiar 
slanting position of the handle of the malleus, and from the fact 
that it was uncommonly thick under the short process, he diag- 
nosticated a united fracture of the manubrium. 

Hyrtl, is quoted by Von Troltsch, as having described such an 
united fracture in the malleus of a prairie dog. This fracture 
was also situated just under the neck of the malleus. The mem- 
brana tympani of this animal is, according to Hyrtl, very super- 
ficially situated. 

1 Von Troltsch on the Ear, second American edition, p. 151. 



FRACTUEE OF HANDLE OF MALLEUS. 275 

Dr. Weir's case is one of ununited fracture. ' A man, aged 
thirty-two, came to Dr. Weir's clinic, at the New York Eye 
and Ear Infirmary, on May 11, 1867, and gave the following 
history : Four months previously he fell into an open area-way. 
a distance of about fifteen feet. He became unconscious, and 
remained so for nearly sixteen hours. He had been informed 
that his right ear bled for about an hour. Upon returning to 
consciousness he felt a severe pain from the right ear, across 
the forehead to the other ear. The pain lasted for nearly a 
month, and gradually diminished ; but the great tinnitus, which 
dated from the time of the injury, continued unabated. There 
was no history of any foreign body having entered the ear. The 
watch was heard upon the affected side when pressed firmly 
upon the ear. 

The drum membrane was normal in color ; but there was an 
irregularity in the handle of the malleus. The bone was found 





Fig. 79. Fig. 80. 

to be fractured a short distance below the short process, pre- 
senting the appearance shown in the engraving. The broken 
ends of the bone were completely and transversely displaced. 

When Dr. Weir caused the patient to perform the Valsal- 
vian experiment, the fragments came into apposition, and the 
line of the bone became regular ; but the posterior portion of 
the membrana tympani projected unduly forward from want 
of support. In a few moments the displacement recurred, witli 
corresponding sinking of the posterior of the drum membrane. 
Dr. Weir's colleagues— Drs. Hackley and Simrock — thought that 
a faint whitish line, posterior to the malleus, might be a cicatrix 
from a laceration of the drum-head. The patient did not return 
to the infirmarv. 



1 Transactions American Otological Sooiety, 1870. 



CHAPTER XL 

ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 

Nomenclature. — Statistics. — Symptoms. — Treatment. — Leeches. — Paracentesis — Sub- 
acute Catarrh. — Hemorrhagic Intiammation of the Middle Ear. — Aural Hemor- 
rhage in Bright's Disease. — Vascular Tumors of the Drum-head. 

The practitioner or student, who is entering upon the study of 
aural disease, will find, I think, some advantage in beginning 
with an outline map of the territory which he is about to tra- 
verse. For this reason, at this point as at the beginning of the 
discussion of diseases of the external ear. a list or classification 
of the diseases of the middle ear is given : 

I. Acute catarrhal inflammation. 
II. Sub-acute catarrhal inflammation. 

III. Hemorrhagic inflammation. 

IV. Acute and sub -acute suppurative inflammation. 
V. Acute serous inflammation. 

VI. Chronic non-suppurative inflammation. 
VII. Chronic suppurative inflammation, with its conse- 
quences. 
VIII. Neuralgia of the middle ear. 

If we were to form our estimate of the frequency of acute 
catarrhal or suppurative inflammation of the middle ear, simply 
from the number of cases that are found in the statistical tables 
of writers on these diseases, we should come to an erroneous 
conclusion as to the number of persons who suffer, at one time 
or another, from them. Acute catarrh of the middle ear. is 
actually a very common disease in our northern climates. It is 
rather difficult to find a grown person who has not, at one time 
or another, suffered from "earache." Earache is the popular 
name for acute catarrh of the middle ear. My own statistics 
show that of 4800 cases of aural disease, seen in my private 
practice, 174 were cases of acute catarrh of the middle ear, 137 
of acute suppurative, and 3 of acute hemorrhagic inflammation 
of the same part. 



STATISTICS OF ACUTE DISEASE OF MIDDLE EAE. 



277 



Burkner's tables, 1 in a total of 43,730, only exhibit a total of 
6180 acute affections of the middle ear. This table includes 
acute myringitis and acute inflammation of the Eustachian tube 
— diseases that are properly included among those of the middle 
ear. 

The following table, also illustrates the comparative infre- 
quency with which acute affections of the middle ear, are seen 
in hospitals. It will be found, however, that the proportion of 
acute aural diseases increases, year by year, when special hos- 
pitals are provided. 

The advance of otology has been greatly hindered by the 
notion quite prevalent in the profession, as well as among the 
laity, that while a nurse or mother is quite competent to treat 
an acute aural disease, a physician, and perhaps a specialist, is 
needed when it becomes chronic. 



Table showing the Proportion of Acute Cases of Disease of the Middle Ear to the 
Whole Number of Aural Cases.* 



Hospitals. 


Year or period. 


Whole 
number. 


. Acute in- 
flammation 
of middle 
ear. 


Newark Eye and Ear Infirmary 


1883 
13 yrs. 
13 yrs. 

2 yrs. 
3 yrs. 5 mos. 

1883 

1882 

1882 

1882 
12 yrs. 
1882-83 


964 

9,611 

10,335 

788 
1,088 
2,875 
2,889 
1,057 

545 
11,747 

611 


228 


Brooklyn Eye and Ear Hospital 

Manhattan Eye and Ear Hospital 


1,617 
1,544 


Baltimore Eve and Ear Hospital 


169 


Glasgow Western Infirmary 


130 


Massachusetts Eye and Ear Infirmary 

New York Eye and Ear Infirmary 


196 
258 


New York Ophthalmic and Aural Institute . . . 
St. Michael's Hospital, Newark 


84 
41 


Philadelphia Dispensary 

Clinica Otojatrica, Rome . 


1,758 
30 










42.510 


6,055 



It will be seen from the above table, that acute affections of 
the middle ear were about one-seventh of the whole number. 
This corresponds pretty accurately with Burkner's statistics. 

That this disproportion does not arise from an actual rarity 
of the affection, I think a little thought will show. Those pain- 
ful diseases very often never reach a practitioner, ami are treated 
at home, a fact which accounts for their relative infrequency in 
statistical tables. 



1 Archiv fiir Ohrenheilkunde, Bd. XX.. lSS:i. 
2 Sub-acute cases are not included in this table. 



278 ACUTE CATAEEH OF MIDDLE EAE. 

Every general practitioner will at once recall the fact, that 
it is often incidentally mentioned, when perhaps he is visiting a 
family suffering from other diseases, that one of the children has 
had a severe earache all night, and that there has been great 
difficulty in quieting the fearful pain. Very often, indeed, the 
fact will be added, that the pain is not yet subdued, and that 
the family have quite exhausted the means at their disposal for 
relieving it ; and yet, taught by tradition and experience, they 
do not expect anything from the physician, whose aid becomes 
so efficacious for the pain of colic or of peritonitis. It is to be 
feared that many physicians stand helplessly by, and allow an 
acute catarrh of the middle ear to run on to suppuration of the 
drum-head, or, worse still, to periostitis of the mastoid or to 
meningitis, without an attempt at interference. 

A little later, in the discussion of this affection, we shall dis- 
cover, I think, that the means at our disposal for its relief are 
ample, and that they have what may almost be termed a bril- 
liant effect, when properly used ; but I wish in the outset to im- 
press the fact upon the minds of my readers that the commonly 
neglected earache of the household is identical with the disease 
known as acute catarrhal inflammation of the middle ear. It 
will then be evident that we are dealing with an extremely 
practical subject, and one in which every family practitioner is, 
or should be, very much interested. 

The symptoms of this affection are so characteristic that in 
the adult they point unmistakably in the most cases to its seat. 
I say in the adult, for in young children who have not yet learned 
to speak, the diagnosis sometimes becomes very difficult, and it 
is not always possible. 

Symptoms. —The symptoms of acute catarrh may be enumer- 
ated in the following order : 

Subjective. 

1. Pain, referred to the depth of the ear, or of a neuralgic 
character, and passing from the throat to the ear. 

2. A sense of fulness in the same part. 

3. Noises in the ear. 

4. An unnatural, hollow sound of one's own voice. 

Objective. 

1. Vascular injection. 

2. Bulging outward of the membrana tympani. 

3. Impairment of hearing. 

4. Catarrh of the pharynx and Eustachian tubes. 

5. Fever. 



ACUTE CATARRH OF MIDDLE EAR. 279 

The pain is very often the first symptom that is observed. 
Children old enough to speak awake from sleep crying, "My 
ear, my ear." Adults find themselves without warning attacked 
by a pain which causes the most intense agony — a pain which 
forces the strongest men to shriek and tremble, while children 
affected with such a disease soon cause the attendants to believe 
that the brain must be the seat of trouble. Sometimes, however, 
patients with good habits of observation notice that the pharynx 
feels thickened and full, and that the throat is sore, a short 
time before the pain in the ear begins. I am inclined to believe 
that most patients are aware of what, for the want of a better 
name, may be termed a thickness of hearing, a fulness in the 
ears, before the attack of pain occurs. This pain is described by 
some patients as beginning in the throat and crawling along the 
Eustachian tube. It is a disease, however, which may be said 
to be sudden in its origin, and one which jumps at a bound to its 
height. It will pass over the acme, in most cases, unless at once 
arrested, into acute suppuration of the middle ear ; a disease 
which, strangely enough, some practitioners seem to invite, 
judging from the expression once at least commonly heard, 
" It is a gathering of the ear, from which we shall get no relief 
until suppuration is established." I intend to combat this idea 
in the discussion of the treatment. It is certainly an erroneous 
and mischievous view of a serious disease. 

The sensations of fulness, the noises in the ear in acute 
inflammation, are very distressing. The latter symptom, the 
technical tinnitus aurium, usually lessens and changes its char- 
acter with a cessation of the pain. It changes from a puffing 
sound, like the puff of a miniature steam-engine, to a ringing or 
buzzing sensation. The feeling of fulness usually lasts for some 
days after the pain has passed away. 

As I have said, the diagnosis of this disease is often difficult 
in young children, because they are unable to locate the seat of 
the pain in words. If, however, we watch a child carefully who 
is suffering from pain in the ear, we can usually narrow it down 
to the region of the head. Then by means of pressure upon the 
tragus, observing if the child winces at this, we can generally 
form a conclusion as to the origin of the pain. The disease with 
which infantile catarrh of the middle ear is apt to be confounded 
is an affection of the membranes of the brain. When we re- 
member the anatomy of the ear, especially that of the tympanic 
cavity, we can readily appreciate the fact that an acute inflam- 
mation of the middle ear, may easily cause hyperemia of the 
membranes of the brain through the roof of the tympanic cav- 
ity, or of the labyrinth, through the fenestno o( the thin wall 



280 SYMPTOMS OF ACUTE CATARRH. 

separating the tympanum from the cochlea and semicircular 
canals. When we also consider, as shown by Politzer, that the 
vascular communication is direct, through vessels situated in 
this partition, we are not surprised that a congestion or inflam- 
mation of the middle ear, especially in infants and young chil- 
dren, may cause very serious head symptoms. Besides this, the 
physiological process of teething, is often credited with a great 
deal of pain, which more properly belongs to the ear. With a 
certain class of what may be called easy-going practitioners, the 
diagnosis of difficult dentition, is often sufficient to cover a mul- 
titude of painful symptoms. Accordingly, gums are needlessly 
lanced, and dangerous delays are allowed, until a discharge of 
pus through the drum-head, makes the diagnosis for the little 
sufferer. 

Pouring warm water into the auditory canal will usually 
temporarily relieve an infantile earache ; and in this procedure 
we have a means of diagnosis which is always at hand. I have 
seen children who were crying with pain from inflammation of 
the middle ear, go to sleep in a few moments after warm water 
has been poured into the canal. Sometimes, however, this pro- 
cedure will fail to give relief, and we must depend for a diag- 
nosis upon the objective symptoms, found in the color of the 
membrana tympani, of which I shall soon speak. 

Adults sometimes mistake the pain from inflammation of the 
lining membrane of the middle ear, for what is termed neuralgia. 
I have seen cases where an anti-neuralgic treatment by means 
of quinine and opium, had been tried in vain for a disease which 
was really an inflammation of the mucous membrane ; but adults 
usually locate the seat of trouble with exactness and accuracy. 
The pain is indeed neuralgic, and a moment's consideration of 
the rich supply of nerves to the cavity of the tympanum, will 
give the reason for the fact that the pain follows the course of 
the fifth nerve. 

This mistake in diagnosis is very similar to the one made 
when acute glaucoma is thought to be neuralgia. Neuralgia of 
the tympanic cavity is a very rare affection. When it does 
occur, the absence of the symptoms of inflammation will indicate 
the true diagnosis. 

The objective symptoms are chiefly to be sought in the mem- 
brana tympani. There is sometimes a pinkish hue to the whole 
membrane, again the vascular injection is around the periphery 
of the drum-head, and along the handle of the malleus, while 
the other parts of the membrane remain of their normal color. 
An acute inflammation occurring in a drum membrane rigid, 
thickened, and opaque from former inflammation, is more apt 



SYMPTOMS OF ACUTE CATARRH. 281 

to show localized redness than the diffuse pinkish tint, that is 
seen when inflammation occurs in a membrane that has been 
previously healthy. 

At other times the redness is so intense as almost to prevent 
any recognition of the drum-head, except as an evenly red sur- 
face in which no vessels can be traced. 

I think there is always some increased vascularity of this 
membrane, in every case of acute inflammation of the lining of 
the tube and the cavity of the tympanum, so that we may find 
in this symptom the deciding point in doubtful cases, even in 
an infant. The membrane has, however, at times the appear- 
ance of glass that has been breathed upon, without any evident 
increase in vascularity, even where there is acute inflammation 
going on in the middle ear. 

The impairment of hearing is not always marked in the stage 
of pain. The hearing power may even be augmented and be 
painfully acute during the first stage of the disease. In cases 
of chronic aural catarrh, in which an acute inflammation had 
supervened, I have known many instances where the acuteness 
of hearing was found on accurate examination to be markedly 
increased. It may be increased also in acute cases occurring in 
persons whose ears had been previously healthy ; that is to say, 
sounds may seem very loud to them. In such a case there is 
probably hypersemia of the vestibule or cochlea, besides that of 
the tympanum. 

Bulging outward of the membrana tympani is a symptom 
that may often be observed after the first forty-eight hours of 
an attack of acute catarrh. If the disease continue longer in 
an acute form, spontaneous perforation is apt to, but does not 
always occur. This bulging outward I have most frequently 
observed in the posterior and inferior quadrant, but also in 
Ghrapnell's membrane, and usually in the posterior portion of 
this membrane. It is sufficiently marked to be detected by 
any one who is at all familiar with the examination of the 
normal membrane. In rare cases — I believe I have seen but 
two in my experience — the imperforate membrana tympani 
will be found to pulsate synchronously with the pulsations of 
the heart. As is well known, it is quite common to observe a 
pulsation of the vessels of the cavity of the tympanum in cases 
of acute and chronic suppuration of this part ; but pulsation 
of the imperforate membrana tympani is a rare symptom. 
There must be great increase of the tension o( the membrane 
from the pressure of the blood column or of mucus behind it 
when this occurs. Increased secretion from the pharynx and 
region of the posterior nares is almost always observed in 



282 CAUSES OF ACUTE CATARRH. 

cases of acute catarrh ; but it requires but a mere mention at 
this point. 

Febrile symptoms are almost always present in cases of the 
disease under discussion. The temperature is usually consider- 
ably increased in a severe case, so that the general aspect of the 
patient, suffering from great local pain, impairment of hearing, 
and a dry, heated skin, is one of intense suffering. Yet this is 
the disease which many physicians allow to run its course, 
without any of the antiphlogistic treatment that they would at 
once resort to, were any other organ of the body similarly at- 
tacked. 

In completing this description, it should also be said, that 
there are cases of acute catarrh of the middle ear in adults as 
well as in children, where while the symptoms of impairment of 
hearing, a sense of stuffiness in the head, redness and bulging 
of the drum-head, a peculiar hollow sound of one's own voice, are 
marked, there is no considerable pain, or if there has been, it 
has passed away before the physician has reached the patient. 
These, however, are exceptional cases. 

Causes. — The causes of this disease are manifold. Any un- 
due exposure to the influence of cold may produce acute catarrh 
of the middle ear. Getting the feet wet, the surface of the body 
chilled by standing or walking in the cold, are frequent causes 
of earache. A draught of air blowing, for instance, through the 
window of a railway carriage in rapid motion, is sometimes a 
cause of acute catarrh. 

Ducking the head under water, and allowing the water that 
enters the auditory canal to remain there, is another cause. 

Surf -bathing, especially in those people who habitually suffer 
from catarrh of the nares and pharynx, thus may become a 
cause of acute inflammation of the middle ear, as well as of the 
auditory canal. The salt-water may enter the nostrils and Eus- 
tachian tube and cause the disease, or a wave may deluge the 
auditory canal and injure the drum-head, and thus affect the 
middle ear. Yet, considering the great extent to which surf- 
bathing is practised in the United States, the number of cases 
of inflammation of the ear caused by it is very small. I have 
spent several summers where surf-bathing is extensively en- 
joyed, and I have heard very little of its evil effects. I believe 
the cases of disease of the ear caused by it, occur chiefly among 
careless and ignorant bathers, or in those who already suffer 
from chronic aural or naso-pharyngeal disease. Prolonged 
bathing and diving in still water, are much more apt to cause 
congestion of the middle ear than surf-bathing. 



CAUSES OF ACUTE CATARRH. 283 

Many cases of aural disease are said by those who suffer 
from them to have originated in the following way. " I got my 
ears full of water and never could get it out," is the fanciful 
statement of many patients who mistake the feeling of fulness 
in an inflamed middle ear, for that from water remaining in it. 
Surf -bathing is of such value as a tonic to many debilitated sys- 
tems that I do not hesitate to advise it, even to patients with 
aural disease, under proper precautions, such as : 

1. Take a bath of not more than five or ten minutes in duration. 

2. If the ears are affected by chronic suppuration, close the 
meatus with cotton. 

3. Never allow a wave to strike the side of the head. 

4. Indulge very sparingly, if at all, in swimming or diving 
through the breakers. 

Constitutional diseases, such as small-pox, scarlet fever, and 
measles, in which the pharynx is affected, are very common 
sources of acute aural catarrh. Pneumonia and bronchitis very 
often have this affection as a consequence. Coryza or cold in 
the head, however caused, very often gives rise to acute inflam- 
mation of the ear. 

It arises in the course of syphilitic affections of the pharynx 
and posterior nares ; but, contrary to what has been said by 
some authors, I have found no pathognomonic evidences of syph- 
ilis in the character of the pain or the appearance of the mem- 
brana tympani in such cases. 

Cerebro-spinal meningitis, is also a prolific source of acute 
inflammation of the middle ear. 

The origin of acute catarrh, is chiefly to be sought for in the 
faucial extremity of the Eustachian tube, and not in the audi- 
tory canal. This explains the fact, that it is much more impor- 
tant for patients liable to aural disease, to protect the external 
surface of the body and the extremities from the cold, than the 
meatus and auricle. * 

Yet it is not to be denied, that inflammation of the middle 
ear does occasionally extend from the canal, through the mem- 
brana tympani, and not through the Eustachian tube, for a 
draught of air upon the side of the head will produce acute aural 
catarrh, and if cold water enter the ear through the meatus ex- 
ternus, and remain for a considerable time, it may also produce 
acute catarrh of the middle ear. 

The use of the nasal douche for the treatment of naso-pha- 
ryngeal catarrh, may also produce acute inflammation of the 
ear, as I first showed. 1 My experience has since been continued 
by many other observers. 

1 Arohives of Ophthalmology and Otology, vol. i.. No. 1. 



284 ACUTE CATARRH — TREAT3IEXT. 

In the description of the treatment of the pharynx and nares 
in the course of chronic aural inflammation, the subject of the 
use of the nasal douche will be more fully discussed. 

The occurrence of acute catarrh of the ear, in scarlatina, 
measles, naso-pharyngeal catarrh, and pneumonia, is, I think, 
favored, by the common practice of giving large, or compara- 
tively large, doses of sulphate of quinine in these cases. This 
invaluable remedy should, in my opinion, be given with great 
caution in these diseases, since the disposition to extension of 
the inflammation to the middle ear, exists strongly in all these 
constitutional affections. Quinine is quite sure to aggravate 
aural symptoms, if they already exist, and in young children it 
may excite them. I have several times seen children suffering 
from acute aural catarrh, in whose ears the administration of 
quinine had, from the very first dose, steadily aggravated the 
pain, until the discharge of pus from the tympanic cavity ex- 
plained the high temperature, which should have been combated 
by local antiphlogistic remedies, instead of by an antipyretic' 

Treatment. — The proper treatment of acute aural catarrh is 
predominantly an antiphlogistic one. The disease is an inflam- 
mation of the severest form, and can only be successfully com- 
bated by such means as local blood-letting, quiet, warmth, and 
opium. As has been said, a neuralgia of the middle ear, that is 
to say, pain without other symptoms of inflammation, is ex- 
tremely rare, yet an inflammation of the middle ear, is very often 
treated as would be a case of facial neuralgia ; or we might even 
say, that the ordinary treatment for acute aural inflammation is 
pre-eminently empirical and without reason. From the time of 
the ancients down to our own day, all kinds of decoctions and 
mixtures have been poured into the ears to relieve earache. 
Some of these agents are of a negative or slight value : many of 
them are of a positively harmful nature. To the former class 
belong such applications as sweet-oil and laudanum, glycerine, 
molasses, and so on. To the latter class belong Haarlem oil, 
Cologne water, ether, and all stimulating applications. Poul- 
tices are remedies often used ; but while they generally quiet 
pain, their application is so dangerous to the integrity of the 
drum membrane, especially if they be used for many hours in 
succession, that the practitioner will do well to avoid them, un- 
less other means cannot be employed, or when the latter prove 

1 I may refer the reader to an article upon this subject by myself, in the Medical 
Record, February 8, 1883, and in the Transactions of the Medical Society of the State 
of Xew York, 1883, as well as to an article on " Colds in the Head/' in the Transactions 
of the same Society of 1880, p. 243. 



ACUTE CATARRH — TREATMENT. 285 

ineffectual. In some cases, however, the urgency of the pain 
will demand that poultices be employed. The chief thing to be 
done in this disease is to decrease the heat, swelling, and vascu- 
larity of the parts. Applications of a stimulating nature, made 
to the membrana tympani, certainly cannot do this ; and mere 
emollients, such as sweet-oil, have a very transitory effect. 

I would place local blood-letting as the chief and first remedy 
in acute aural catarrh. This blood-letting should be performed 
by means of leeches applied to the tragus, and not to the mas- 
toid process. Wilde, and Troltsch, have taught the profession 
that this is the best point for the application of leeches in in- 
flammation of the ears, and the reasons therefor. At this point, 
the blood is most easily drawn from the cavity of the tympanum 
— the vessels supplying it, and the drum membrane, inosculating 
here. The application of from one to six leeches, according to 
the severity of the disease and the age of the patient, will usu- 
ally be sufficient to quiet the most severe pain in the ear, and to 
check the intensest form of catarrhal inflammation. I have 
seen almost magical effects from their use. One of the most 
striking of the cases in my note-book is the following : I was 
called on a very severe winters day to see a young gentleman 
in a neighboring city, who had been suffering for two days from 
acute pain referred to the ear. I found the symptoms of acute 
aural catarrh, in a reddened but intact drum membrane, con- 
gested pharynx, and so forth. When I entered the room he 
seemed to be in mortal agony. He said that he had not slept for 
forty-eight hours, and his anxious countenance verified his asser- 
tion. I at once sent out for some leeches, and caused one to be 
applied to each ear, and before they had dropped from the tragus 
he was asleep, and went rapidly on to perfect recovery. Such 
cases might be multiplied, for they are of frequent occurrence in 
hospital and private practice. 

Leeches are, however, a troublesome remedy, and in country 
districts they are not always to be had. In their absence I place 
the use of warm water as next in efficiency. This should be 
poured continuously into the ear. and not used by means oi' a 
syringe, as I have known patients to employ tin 1 water when 
told to pour warm water into the ear. The fountain syringe or 
the Fayette douche (see illustration on page 128) is the best 
means of which I know for applying warm water to the ear. 
Sometimes the warm water is unpleasant, instead o\' grateful. 
to the patient, and then the vapor of water or the smoke from a 
cigar or pipe may be conducted into the ear. Children may some- 
times be relieved in the beginning of an attack o( acute aural 
catarrh, by breathing into the affected ear for a very few min- 



286 ACUTE CATAREH — TREATMENT. 

utes. If leeches cannot be had, and the use of warm water or 
of steam does not subdue the pain, cups — wet or dry — applied 
around the auricle, are sometimes of use, as well as blisters, or 
Hourteloupe's artificial leech may be used. 

Poultices, as I have said, are only to be used as a last resort. 
Then they should be made small enough to be put in the canal, 
and one may also be placed around the ear, leaving the auricle 
free ; and their use should be given up as soon as the inflamma- 
tion has abated. 

If the patient or his friends are told to apply the leeches, the 
exact spot upon which they are to be placed should be marked 
with ink, or they will be put on the lobe, or on the neck, or in 
some other position where their use will do no good. I have 
quite often found, that a neglect to state just where the leeches 
should be applied, has caused all the efforts to relieve pain to be 
of no value. Rohland's styptic cotton — a preparation of cotton 
in a solution of alum — prepared by Dr. Eohland, of this city, will 
be found a very efficient means of arresting the hemorrhage f roni 
a leech-bite. The bleeding should, however, usually be encour- 
aged, by the use of warm compresses, for an hour after the 
leech has dropped from the ear. 

Scarification of the drum-head, as recommended by Blake, is 
also of service in mild cases. It requires a practised hand for 
its performance, however, much more than a paracentesis. 

Paracentesis of the drum membrane is a very efficient remedy 
at times, when there is bulging of the drum-head, and we see 
that perforation is imminent ; or even in cases of prolonged pain 
without bulging of the membrane, when the leeches have been 
used at too late a period, or have proved ineffectual. 

Schwartze, of Halle, taught us the value of this means of 
treatment in acute cases, and I have found it of great value. I 
would even pass a cataract needle through the posterior portion 
of the membrana tympani, in any case, whether bulging was 
seen or not, when the use of leeches did not markedly diminish 
the severe pain within a few hours. I have done so with strik- 
ing effect in some cases. Yet leeches and warm water, if 
promptly used, will usually check the progress of even the se- 
verest case. Very often, however, we are not called until the 
disease has advanced so far as to involve every part of the 
middle ear, when periostitis of the mastoid has occurred, and sup- 
puration seems to be inevitable. 

Paracentesis of the membrana tympani should be performed 
while the head of the patient is well supported, and a good light 
is thrown upon the membrane by means of the otoscope attached 
to a forehead band. A needle, such as shown on the next page, 



ACUTE CATARRH — PARACENTESIS. 287 

is the one I employ. The point of opening should be determined 
by the seat of the greatest amount of bulging, which I have 
found generally to be in Shrapnell's membrane, and in the pos- 
terior and inferior quadrant of the membrane. 

I have tried the instruments with an angular handle, but I 
have, after much experience, concluded that a straight instru- 
ment is so much more easily managed, that this facility in use 
much more than completely balances any value from not shut- 
ting off the light from the canal, said to belong to the other in- 
struments. A needle, such as is used in the operation of di- 
scission of a soft cataract, is a very good instrument for making 
an opening into the membrana tympani. 

The operation causes so little pain and it is so brief, that this 
element does not enter into the consideration of the surgeon. I 
have found the light of a candle about the best and most con- 
venient source of illumination, when the operation is to be done 
in a sick-room, and the patient is in bed. For acute cases a 
thorough puncture, through which the blood, mucus, or pus can 
be drawn, is usually an opening large enough to relieve pain. 
I have more frequently performed the operation in cases where 



Fig. 81. — Paracentesis Needle. 

the severity of the pain has passed, and yet I have also per- 
formed it with the happiest of immediate results when the pa- 
tient was at the height of distress. 

If we find on examination that the mastoid region is red, hot, 
tender, and swelled, it will be often necessary to make an inci- 
sion through its tissues down to the periosteum; but it is only 
very rarely that this is the case in acute aural catarrh. Such a 
state of things is more apt to be found in acute or sub-acute sup- 
puration, or as a result of chronic suppuration, under which 
heads the subject will be fully discussed. 

The condition of the pharyngeal mucous membrane should 
at the same time be attended to, by means of gargles and ex- 
ternal applications. A saturated solution of chlorate of potash 
forms one of the best of applications to the pharynx, while the 
neck may be enveloped in a warm- water poultice. 

The Eustachian catheter and Politzer's method of inflating 
the middle ear should be used as soon as the acute symptoms 
have subsided, say in forty-eight hours. If employed with gen- 
tleness, there need be no fear of aggravating the subdued in- 
flammation into a relapse. Indeed, inflation often relieves pain 
by emptying and ventilating the tympanum. 



288 ACUTE CATARRH — TREATMENT. 

The hearing should be accurately tested by means of the 
watch and tuning-fork, in order to see. after the pain has sub- 
sided, if any impairment has occurred. If only one ear be 
affected, careless patients will believe that the hearing is per- 
fectly good, after the pain and fulness have passed away ; but 
the physician should be sure of this for himself. In half -treated 
acute catarrh, are laid the foundations for that insidious and 
obstinate disease, chronic non-suppurative inflammation of the 
middle ear. 

While this energetic local treatment is carried on. the atten- 
tion of the physician should be turned to the general system. 
It will often be necessary to give a full dose of opium or mor- 
phine at bedtime. It is somewhat remarkable, however, that 
opium has very little effect, when used without local depletion, 
to quiet the pain from inflammation of the middle ear. Very 
large doses will be taken in vain, unless the local means that 
have been described are also employed. 

The patient should be kept in the house, and in a well- 
warmed room, during the stage of pain and fever. Pediluvia 
and diaphoretics are hardly necessary in case the pain is once 
subdued. The diet should be nourishing. The patient should 
be enjoined to keep his skin in good order by means of frequent 
bathing, in order to prevent relapses. The improper habits of 
life, or the exposures to cold, that have induced this attack, 
should be carefully sought out, in order that future ones may 
be avoided. 

A daily sponge-bath in a warm room, using cool water in 
summer and tepid in winter, followed by vigorous rubbing with 
a coarse towel, will be found of real service in preventing re- 
lapses of aural disease. Xot every patient, however, can tolerate 
cold water, although I think every moderately well person will 
be the better for a daily bath of the whole surface of the body. 
A little discretion must therefore be allowed the individual as 
to the temperature of the water used. The shower-bath and the 
plunge, as well as the habit of pouring water into the ears, 
should be discouraged. 

The practitioner who. while treating a grave constitutional 
disease, finds this local inflammation breaking out. should by 
no means allow the severity or danger of the constitutional 
symptoms to prevent him from the proper treatment of the 
acute aural catarrh. The local and constitutional treatment 
can well go on together ; while the neglect of the ear at the 
proper time may lead to irreparable damage not only to the 
health and prosperity of the patient, but it may destroy his life. 

AVe cannot be too much impressed with the fact that a neg- 



ACUTE CATARRH IT* THE EXANTHEMATA. 289 

lected acute aural inflammation may lead, through suppuration 
of the middle ear, with all its consequences of caries, polypi, 
meningitis, cerebral abscess, pyaemia, to the most deplorable 
results. 

Better would it be for a child suffering from scarlet fever or 
measles to die from the disease, than to recover from the con- 
stitutional affection only to succumb, with great misery, to the 
effects of the neglected inflammation of the middle ear. It is 
to be hoped that the neglect of treatment of the ear, will not pre- 
vail in the next generation to the extent that it does in ours. 

I was very much interested in a complaint made by a dis- 
tinguished surgeon of New York, who, in a discussion upon the 
effects of scarlet fever and measles upon the ear, stated that 
while writers on aural surgery said much about the neglect of 
diseases of the ear, occurring during the course of the exanthe- 
mata, he had found no means of doing anything to prevent the 
breaking out of such disease while the measles or scarlet fever 
were going on, and he did not know, after all the warnings, 
that there was anything really to be done. Now, in answer 
to this, it may be said that it is not claimed that otitis media 
may be always averted in the course of scarlatina or rubeola, 
but sometimes, if the physician be on the lookout for it, it may 
be aborted, so to speak. If a child begin to toss its head about 
as if in pain, or if it become hard of hearing, the tragus may 
be at once examined to see if pressure upon it cause or increase 
pain, the drum-head may be looked at and a diagnosis made. 
If there be congestion of the ear, the warm douche will often 
relieve it at once. If not, we have blisters, leeches, and para- 
centesis of the membrana tympani. If, however, the attack 
cannot be aborted and goes on, certainly we may by these same 
means alleviate or stop the pain, and modify the course of 
the disease, so that recovery of the ear will usually go on step 
by step with the general convalescence, and the patient will not 
barely recover of the exanthem, to suffer the horrors of chronic 
suppuration of the middle ear. All that writers on aural sur- 
gery ask that general practitioners shall do in cases of acute 
inflammation of the middle ear, occurring in the exanthemata. 
is, that they treat them as they would the same disease occurring 
independently. 

The practitioner who looks through the generally excellent 
works on the diseases of children, will be painfully impressed 
with the fact, that very little attention is given to the common 
complications of infantile diseases with acute catarrh and sup- 
puration in the ear. 

The course of a case of acute aural catarrh, promptly treated 
ll) 



290 ACUTE CATAEEH — TEEATMENT. 

in the manner that has been outlined, usually ends in complete 
recovery, with integrity of the structure and functions of the 
ear. In less favorable cases suppuration occurs ; but this is 
usually tractable, and even then the organ may be restored to 
complete usefulness. 

It is unfortunately true, however, that an acute catarrhal in- 
flammation of the middle ear, even under judicious management, 
may go on to be a suppurative one, from which death may occur 
from extension of the inflammation to the brain. More will be 
said of this, however, in the chapter upon acute suppuration. 

It is sometimes stated that the treatment as described in 
the preceding pages is too heroic, and that milder means than 
leeches, paracentesis, scarifications, an incision down to the 
periosteum of the mastoid, may be employed, not only with 
safety, but with benefit to the patient. The use of leeches has 
been especially objected to, on account of the local irritation 
and even inflammation they are said to frequently cause. Par- 
acentesis of the drum-head, it is said, is a dangerous operation, 
and often performed unnecessarily, and so forth. To all this, I 
can only say that acute catarrh, or acute suppuration of the 
middle ear, are serious and rapidly progressing diseases that 
admit of no temporizing, of no delays in active antiphlogistic 
treatment. I have not been speaking of subacute inflammatory 
affections, of neuroses in hysterical and anaemic subjects, but 
of a sthenic inflammation, with its pain and its possibilities of 
rapid advance from the tympanic cavity to the membranes of 
the brain, to the general circulation, or when its progress takes 
a more favorable turn, to the membrana tympani. To combat 
this disease, only local antiphlogistic treatment will be of avail. 
Those who wish to arrest pain quickly, to prevent dangerous 
consequences from an extension of an inflammatory process, 
will find the active treatment that has been here described 
will not disappoint their expectations. Some of the arguments 
against the means now in vogue among the modern otologists, 
have been based on the incorrect assumption that they are em- 
ployed in mild cases when less active means will be more agree- 
able, and equally efficacious. I have been careful, however, as 
I believe, to show that local blood-letting, paracentesis, and cut- 
ting down to the periosteum, with confinement to a room, are 
chiefly to be employed in severe cases. That an acute inflam- 
mation of the middle ear is a severe case, certainly no one will 
deny who has been called to treat it, or who has unfortunately 
experienced it. 

I believe as fully as any of my professional brethren, in the 
natural course of diseases, which it is often better not to attempt 



SUB-ACUTE CATARRH. 291 

to check ; in the vis medicatrix naturce ; in the danger of doing 
too much for many cases, but the disease now under considera- 
tion is one which I believe from a long and large experience can 
only be successfully combated by what are known as local anti- 
phlogistic means, among which leeches and the warm douche 
take the first position. 



SUB-ACUTE CATARRH OF THE MIDDLE EAR. 

There is a variety of catarrh of the middle ear, very common 
in young persons and in children, although it also occurs in 
adults, which differs in so many respects from the ordinary type 
of acute catarrh, that it seems to require a more extended notice 
than the references that have been made to it in discussing the 
latter-named affection. I have ventured to term this affection 
sub-acute catarrh of the middle ear. It has many of the symp- 
toms of the truly acute form. The absence of pain is the chief 
distinguishing mark by which it is separated from the latter 
form. Some authors, judging from their statistics, have classi- 
fied it under the head of chronic aural catarrh. Others classify 
it among acute affections. While the former view may not be 
strictly incorrect — for the affection that I am about to describe, 
may last for months, and run into the strictly chronic form — it 
has, in my opinion, more of the characteristics of acute catarrh 
in its nature, and in its readiness to yield to treatment, than of 
chronic inflammation. 

In spite of some adverse criticism, especially by German 
authorities, I think we may justly draw a distinction between 
an acute and a sub-acute affection. If we do so, we shall be less 
likely to fall into the error of treating all recent cases of catarrh 
of the middle ear, as vigorously as we do those that only differ 
from them in being attended by great pain and injection of the 
drum-head. Acute catarrh demands vigorous treatment, while 
the sub-acute form will get on very well with mild measures. 

Symptoms. — The subjective symptoms of sub-acute catarrh of 
the middle ear may be stated as follows : It is observed that the 
patient, without suffering from pain in the ear. or if so. from 
pain that is not long-continued, is very often so hard of hearing 
as not to hear ordinary conversation. Very little is thought of 
this by the friends of the patient, or perhaps by the medical ad- 
viser ; but the trouble recurs, the attacks become more frequent. 
and the period of impairment of hearing more prolonged, so 
that school-life is seriously interrupted. The general health 
may, or may not, be impaired. 1 have seen many such cases 



292 SUB-ACUTE CATATCKH. 

in boys and girls in excellent general health, as well as in the 
delicate and strumous. 

The objective symptoms are as follows : The pharynx is usu- 
ally in a thickened or granular condition, the normal secretion 
is excessive, and it may be changed in quality, and be decidedly 
muco purulent. The tonsils may or may not be hypertrophied. 
The membrana tympani has lost its normal neutral gray color, 
and is of a pinkish hue. The vessels are not usually to be traced 
upon any part of it. It may be exceedingly brilliant. The light 
spot is usually absent, or is smaller than usual ; a fact which 
shows that the drum-head is sunken inward. The experiments of 
Magnus, which have been described in the tenth chapter, show 
that any excessive pressure which pushes the drum-head inward 
lessens, or if the pressure be great enough, obliterates the light 
spot. The hearing, as tested by the watch, is found to be very 
much impaired, and only such conversation as is addressed to 
the patient, with his face toward the speaker, is heard. 

This impairment of hearing in children is very often attrib- 
uted to ''absent-mindedness'' by parents, and to "stupidity" by 
teachers. Children are not usually absent-minded, and when 
they are stupid, there is always a cause, which should be traced 
out, and the poor child not treated as if it were responsible for 
the disease that has rendered it so. Again and again, will the 
practitioner find that he is obliged to correct the false ideas of 
parents and teachers, who do not know that children always pre- 
fer to hear, if they can. Malingering as to deafness is a de- 
ception which children rarely understand, and which they can 
never successfully maintain. A child that does not habitually 
answer at once when addressed, should be at once carefully ex- 
amined as to its hearing power, before it is scolded for absent- 
mindedness. 

Treatment. — It is apt to be the case, that proper hygienic 
rules have not been observed in the management of such young 
patients. They have been allowed to eat and drink food im- 
proper for growing persons ; for example, tea and coffee, pastry 
and so forth, to the greater or less exclusion of simpler and 
more nutritious substances, and thus a capricious state of the 
appetite has been induced. In the case of boys, frequent and 
prolonged bathing or swimming, of which ducking the head 
under water forms the chief part, is sometimes found to cause 
or increase the impairment of hearing. The regulation of the 
diet of such patients, the wearing of flannel next the skin, the 
abstaining from any habits which may be recognized as pre- 
disposing to inflammation of delicate structures, building up of 
the system by a proper therapeutic course, such as the exhibi- 



SUB- ACUTE CATARRH. 293 

tion of (pod-liver oil and iron, with proper attention by the use 
of gargles to the mucous membrane of the pharynx, will per- 
haps in time allow Nature to relieve these cases ; but the im- 
pairment of hearing, which is the most striking and most trou- 
blesome symptom, will be the last one relieved, and it may not 
be relieved at all, and the patient grow up to be permanently 
hard of hearing. We have at our hands, however, in Politzer's 
mode of inflating the ears — a method of treatment that has been 
fully described in the second chapter— a means of instantly im- 
proving the hearing, and thus of removing the most embarrass- 
ing symptom in an instant. 

The wonder and joy depicted on a little patient's face when 
the world of sound opens to him again, after the air has once 
entered the Eustachian tubes and tympanic cavities, is some- 
thing very pleasant to see. In the absence of the air-bag, a bit 
of india-rubber tubing inserted in one nostril, the other being 
closed, through which air is blown from the lungs of the sur- 
geon, will do very well. Indeed, where the subjects are very 
young, I prefer this method, which is Mr. James Hinton's adap- 
tation of Politzer's principle. 

The pathological changes in these cases, which cause the 
impairment of hearing, are probably in some cases simply plug- 
ging of the faucial orifice of the Eustachian tube, in others of 
the calibre of the tube and the tympanic cavity by mucus. Struc- 
tural changes, such as thickening of the mucous membrane, 
adhesive bands, rigidity of the ligaments of the ossicles, and so 
forth, have not occurred. Hence I would not class these cases 
among those of chronic catarrhal inflammation. 

It is probable also that the mobility of the ossicles is inter- 
fered with in some cases by the accumulated mucus as w T ell as 
by the swelling of the articulations. The restoration of the nor- 
mal vibrations of the chain of bones, and the removal of the mu- 
cus explain the sudden increase of hearing power by inflation. 

I append three cases, two of which have been before pub- 
lished; 1 but I have been able to follow them up, and note that 
the recovery was perfect. I again publish them, with an addi- 
tional one of the same character. The cases are very common, 
and it is not therefore for their rarity that they are inserted, but 
that they may perhaps teach how much may be done to instantly 
relieve this form of disease. The practitioner who ignores the 
ear will certainly pass by, among these cases, many which, if 
properly examined and treated, would add very much to his 
reputation, and increase his power of doing good. 



1 American Journal of tin* Medical Sciences, vol. v i i . , p. (.54. 



294 SUB-ACUTE CATAERH— CASES. 



CASES. 

Case I. — F. S. B , aged sixteen, New York, September 1, 1865. Has been 

deaf at times for a number of years, and for the last summer persistently so. 
His general condition is fair ; is well developed. The tonsils had been so much 
hypertrophied as to impede respiration ; but they were removed previous to his 
coming under my observation. The pharynx secretes excessively, as well as the 
nasal mucous membrane. There are numerous granulations scattered over the 
pharynx. The membranae tympani are pinkish, brilliant in appearance. The 
light spot is elongated. The watch is heard about six inches from each auricle. 

Politzer's method was practised three or four times, when the hearing dis- 
tance extended to sixteen inches on the right side, and ten on the left. A gargle 
containing iodine and brandy was ordered to be used twice a day. He was also 
to practice Politzer's method twice a week, in connection with the iodine inhaler. 
The patient continued to improve, and at the present writing, April 20, 1866, the 
treatment has been abandoned, the hearing power being nearly, if not quite 
normal. The patient goes to school every day. He was seen by me for some 
weeks once a week, while his father, who is a distinguished physician of this 
city, carried out the treatment at home, which consisted in the use of the gargle, 
inflating the middle ear by Politzer's method once in three or four days, with 
attention to the general health. 1884. — The patient is now a practitioner of med- 
icine, and has no trouble on account of his hearing. 

Case II. — Girl, aged sixteen, at Eye and Ear Clinic in University Medical 
College, March 28, 1866. Has not heard ordinary conversation for years, and 
has been very much embarrassed in swallowing and breathing, on account of 
enlarged tonsils ; general condition is fair ; the voice is extremely nasal ; only 
hears when addressed in a loud tone of voice ; the watch is heard two inches on 
the right side, one inch on the left ; membranee tympani present nothing strik- 
ing in appearance, except that they are quite brilliant ; the tonsils are excessively 
hypertrophied. The use of Politzer's method immediately improved the hearing 
somewhat, which improvement lasted, according to the patient's statement, about 
a day. When next seen, the tonsils were excised with the forceps and scissors, 
a long outgrowth being dragged down from behind the soft palate on the right 
side, which must have pressed upon the orifice of the Eustachian tube, and then 
the iodized air was driven into the tube. The hearing distance became two feet 
on the right side, and about six inches on the left. An iodine gargle was ordered, 
■with cod-liver oil, a half tablespoonful to be taken three times a day. The 
patient is now under treatment, and still (April 26, 1866) continues to improve, 
hearing very well, with no trouble in respiration. 1872. — I have seen this patient 
several times since, on account of naso-pharyngeal catarrh, and her recovery of 
hearing proves to be permanent. 

Case HI. — Master (sent to me by Prof. Fordyce Barker, January 21, 1873), 

aged fourteen. This boy has had "a cold," and has been very hard of hearing 
for some weeks. He is in excellent general health. The membranae tympani 
present nothing particularly abnormal. The pharynx and nostrils are secreting 
excessively. Hearing distance — right ear, |V ; left ear, the watch is only heard 
when laid on the auricle. He was seen every other day for three weeks, when 
the Eustachian catheter and Politzer's method were used, while a gargle of 



HEMORRHAGIC INFLAMMATION". 29o 

chlorate of potash was employed at home. At the first sitting his hearing dis- 
tance was brought up to £f E. E., -h left, so that conversation was heard with 
much more ease, and when his hearing power became f §• on each side, and was 
still improving, he was allowed to return to his school. 

The use of the catheter when the patients will submit to it, 
and nearly all except infants will do so, causes the action of 
Politzer's method to be more powerful. It probably excites the 
muscles of the tube to more vigorous contraction. When chil- 
dren are too young to swallow on the signal, we may still employ 
Politzer's method, by putting the tube in one nostril, closing the 
other with the finger, and rapidly forcing in the air in spite of 
the child's screams, which are not those of pain. During the 
swallowing motion that the little one involuntarily makes, air 
will enter the tube. It is highly probable that infants sometimes 
suffer from sub-acute catarrh, which if not relieved by local treat- 
ment passes on to a chronic process, which ends in deaf-muteism. 
Where any doubt exists, the little patient should have the benefit 
of it, by the use of Politzer's method, which can do no harm, and 
may do a vast deal of good. The existence of a naso-pharyngeal 
catarrh in an infant, should be carefully considered by the attend- 
ing physician, lest it result in one of the tympanic cavity, and 
there cause changes which must leave permanent impairment of 
hearing. 

The evil consequences of neglected colds in the head are not 
always sufficiently appreciated by our profession. It is from the 
children who suffer frequently from this affection, that the large 
class of persons, whose hearing is greatly and permanently im- 
paired, is annually recruited. It is of the utmost importance 
that all cases of impairment of hearing, should be under early 
supervision, lest a permanent defect occur. Inflation of the 
ear, with general hygienic means, will generally relieve these 
cases promptly. 



HEMORRHAGIC INFLAMMATION OF THE MIDDLE EAR. 

I believe I was the first to report 1 cases of acute aural catarrh 
which had an unusual course and termination — that is to say, 
cases in which the course was very acute and terminated rapidly 
in perforation of the membrana tympaiii without suppuration, 
but with quite an abundant hemorrhage through the drum- 
head. It is well established that hemorrhage into the middle 
ear may occur in the course of kidney disease, just as from the 
vessels of the retina; but the two cases which 1 am about tode- 



1 Transactions o£ the American Otologioal Society, 1878. 



296 HEMORRHAGIC INFLAMMATION. 

scribe certainly do not come under the classification of hemor- 
rhage from blood-vessels made atheromatous by renal disease. 
They are, I think, to be considered as cases of acute inflamma- 
tion of the lining membrane of the middle ear, in which the 
morbid process has an unusually rapid and violent course, so 
that not merely an exudation through the walls of the vessels, 
but an actual breaking down of the walls themselves, occurs ; 
there is then such an accumulation of the blood in the cavity of 
the tympanum that rupture of the drum-head almost necessarily 
follows. It has been often observed that in many cases of para- 
centesis of the membrane, for the relief of inflammation of the 
lining membrane of the drum cavity, blood is the only product 
that escapes. I think these cases are analogous to those which 
I am about to record, and that they serve to explain them. 

Case I. — The first case that directed my attention to hemorrhage through the 
membrana tympani, as a consequence of acute inflammation of the middle ear, 
was that of a young lady of rather delicate organization, who was under the care 
of Drs. Agnew and Loring. The case was seen in consultation with the latter- 
named gentleman, who gave me the history. The patient was deaf from what 
seemed to be hypertrophy of the membrane lining the drum cavity ; the mem- 
brana tympani was thickened, sunken, and immovable ; she was treated in the 
usual manner, i.e., the catheter and Politzer's method were employed, and the 
attempt made by them to force the drum-head outward. On the day or day 
before I saw the patient, and about twenty-four hours after the catheter and 
Politzer's method were used, she was seized with violent pain referred to the 
depth of the ear ; to relieve this, paregoric was dropped into the ear. Dr. Lor- 
ing and I saw the patient in the evening ; the pain had then somewhat abated. 
On examination, I found, after carefully removing the fluid that had been 
dropped in, that the membrana tympani was ruptured, and that blood was issu- 
ing from the pulsating opening. The patient recovered after an erysipelatous in- 
flammation of the auditory canal and side of the face. I did not see her again, 
but Dr. Agnew examined the membrane in a few days, and could find no rup- 
ture, and no trace of it. 

I might, perhaps, be slightly in doubt as to the occurrence of a rupture and 
hemorrhage from the membrane in this case, had I not seen one subsequently 
which was very similar, and where, as in this case, no svppuration occurred after 
the rupture, and consequently no scar remained. The presence of the paregoric 
rendered it somewhat difficult to determine whether the fluid in the rupture 
was blood or not ; but I took this fully into consideration, and determined that 
it was. 

Case II. — This occurred in a gentleman in good health, of forty-seven years 
of age. He smoked excessively, but in other respects his habits were good. He 
had chronic pharyngeal catarrh, but it troubled him very little. He did not 
remember that he had ever had earache as a child or adult. I saw him on 
November 7, 1871. His history was as follows: About 10 o'clock to-day, he 
suddenly experienced a severe pain in his right ear. The pain was so acute that 
the patient was obliged to leave his business and go home. The treatment con- 



HEMORKHAGIC INFLAMMATION. 297 

sisted in the instillation of sweet oil and tincture of opium. There was no 
relief, however, until about 6 p.m., when "a loud report occurred in his head," 
and quite a free hemorrhage occurred. The patient thought more than a tea- 
spoonful of blood escaped. I saw him a few moments after the hemorrhage had 
occurred. The pain had entirely subsided ; the membrana tympani was perfo- 
rated in the anterior and inferior quadrant, and a small quantity of dark-colored 
blood was about and in the opening, while the membrane was pulsating as in the 
former case, or rather the blood column was pulsating in the cavity of the tym- 
panum. This patient fully recovered without any suppuration whatever. The 
opening healed, and the hearing, which was reduced to such an amount as to 
be expressed by the fraction ^ 6 -, was restored to a normal standard. The treat- 
ment consisted in the careful use of an injection of tepid water, just after the 
occurrence of the rupture, with the subsequent use of the Eustachian catheter, 
through which air was introduced, and Politzer's method of inflating the drum- 
head. 

It may be of interest to note that this gentleman died some 
thirteen years afterward of cerebral hemorrhage. I lately 
treated a gentleman in his eighty-fourth year, who suffered 
simultaneously from hemorrhagic retinitis and hemorrhage into 
the middle ear. Absorption of the blood in the tympanic cavity 
and the drum-head was followed by great improvement to the 
hearing. I have also lately seen a case of hemorrhage into the 
drum-head, after the escape of fluid into the tympanum while 
gargling. This latter case, however, is hardly like a true hem- 
orrhagic inflammation of the middle ear which I first described, 
and which is now generally recognized. Not only have cases 
been reported by eminent authorities, 1 but in one hospital 2 it is 
reported that 19 cases have been observed in thirteen years. 
Hemorrhagic inflammation of the middle ear is usually a very 
tractable inflammation whose violence is spent with the hemor- 
rhage. The history of such cases, especially with regard to the 
abatement of the pain as soon as the hemorrhage occurs, fur- 
nishes another argument for an early perforation of the drum- 
head, when great pain is experienced and the drum-head bulges. 

Since the publication of the author's cases of otitis media 
hemorrhagica, Dr. Mathewson, of Brooklyn, and Dr. Hackley, 
of New York, have also observed and reported at a meeting- of 
the New York Ophthalmological Society, cases of acute inflam- 
mation of the middle ear, in which hemorrhage occurred through 
the membrana tympani before any pus appeared. Their course 
was quite similar to that of those I have related, and Dr. Hack 
ley's case occurred in a young woman who had just passed 
through the menstrual period, and the menses reappeared after 



1 Guide to the Study of Ear Disease, by T. MoBride, M.D., \\ 50. Edinburgh, 1884, 

2 Brooklyn Eye and Ear Hospital Report, ISSo. 



298 HEMORRHAGIC INFLAMMATION. 

the aural hemorrhage ceased. Dr. Pomeroy also reports such 
a case, as follows : ' 

A woman of fifty-five was seized with a chill at ten o'clock in the evening, 
which was followed by fever and great pain on the left side of the head and in 
the left ear. The pain continued with more or less severity for five days, when 
Dr. Pomeroy saw the patient and found the membrana tympani intensely red. 
Posteriorly and above it bulged somewhat. The right membrane was also red, 
but did not bulge. The left membrane was opened, and after inflation the 
auditory canal was nearly filled with blood. Two days after the membrane, 
which seems to have closed, was again punctured and a few drops of blood 
evacuated. The patient made an entire recovery without suppuration from the 
ear. The patient had no renal disease and no cerebral symptoms. 



AURAL HEMORRHAGE IN THE COURSE OF BRIGHT'S DISEASE. 

There will, perhaps, be no better opportunity than the pres- 
ent of alluding to those hemorrhages from the tympanic vessels 
that occasionally occur in Bright's disease. Schwartze reported 
such a case 2 in 1868. 

The patient was a non-commissioned officer, of twenty-five years of age, who 
suffered from albuminuria, with retinal hemorrhages. There was also enlarge- 
ment of the liver and spleen, and infiltration of the lungs. On January 16, 
1868, he suddenly complained of pain in his right ear, which had been previ- 
ously sound. When Dr. Schwartze saw the patient, some hours after, the 
membrana tympani was of a bluish-red color and devoid of concavity. Some 
leeches were applied, but they did very little good. The next day the mem- 
brane was of a dark-red color, so that an extravasation of blood into the cavity 
of the tympanum was plainly evident. On the 19th there was an abundant 
serous discharge, and when the ear was cleansed by a syringe, a small blood 
coagulum was removed. Anteriorly and below there was a perforation in the 
membrana tympani, about as large as the head of a pin. In the afternoon a 
whitish mass came out of the ear, in the water that was instilled every ten min- 
utes. This mass, which looked like a fibrous coagulum, was one and a half 
inch long, and two lines broad, and one-half a line thick. On the 20th an- 
other similar mass came out, and on the 22d the patient died. The discharge 
from the ear had then become purulent. 

The microscopic examination of the mass removed, when it was not quite 
fresh, showed an extremely fine granular material, mixed with numerous scales 
of epithelium. The post-mortem examination was made on January 23d. There 
was great hypertrophy and dilatation of the left ventricle. Both kidneys were 
atrophied. The lungs and spleen enlarged. Pneumonia of both lungs. Re- 
tinitis apoplectica, with retinal detachment on both sides. 

Eaks. — Hemorrhagic inflammation of the membrane lining the right cavity 

1 Transactions American Otological Society, p. 86, 1875. 
5 Archiv fur Ohrenheilkunde, Bd. IV., p. 12. 



299 

of the tympanum ; cavity of the tympanum filled with bloody purulent fluid. 
Membrana tympani greatly reddened and swelled, covered by a thin layer of 
pus, and perforated as before stated. The mucous membrane of the Eustachian 
tube was also injected, but not so markedly as the tympanic cavity. No affec- 
tion of the labyrinth. 

In the left ear, of which the patient did not complain during life, the cavity 
of the tympanum was also filled with a bloody serous fluid ; but there was no 
inflammation of the lining membrane. There were small ecchymoses on the 
mucous membrane of the naso pharyngeal space. The mucous membrane of 
the tube was injected, and mostly so at the faucial orifice of the tube. 

In the same year that Schwartze published his case, Dr. 
Gouverneur M. Smith read a paper before the Academy of Med- 
icine, 1 in which he called attention to the fact that impairment 
of hearing was at times one of the symptoms of Bright's dis- 
ease, and a symptom that could not be explained by referring it 
to uraemia. I once treated a case of obstinate suppuration in 
the middle ear, in a man of sixty-one years of age, who, al- 
though suffering from Bright's disease, of which he died, com- 
plained chiefly of neuralgic pains referred to his suppurating 
ear, for three or four months prior to his death. I have now no 
doubt that the renal disease, by its effect upon the tympanic 
vessels, was the cause of the acute suppuration in the ear, and 
that if I had seen the case when the rupture of the drum-head 
occurred, that I would have found it hemorrhagic in its nature. 

In a thesis for the degree of Doctor in Medicine, 2 Paul Pis- 
sot enumerates three forms of diseases of the ear as arising in 
Bright's disease, viz., tinnitus aurium, half deafness, and com- 
plete deafness. This classification is so unscientific that it gives 
no real information. The only important part of this thesis is 
that in which it is stated that Delacharriere has found rupture 
of the membrana tympani, vascularity along the handle of the 
malleus, and sclerosis of the tympanum in cases of impairment 
of hearing occurring in Bright's disease. The supposition is 
then made that the aural symptoms may be due to an oedema of 
the sheath of the auditory nerve. This, it is needless to say. is 
a purely theoretical view. Even the occurrence of aural symp- 
toms in Bright's disease of the kidney has as yet attracted but 
little attention, and, as far as I know, they are somewhat rare, 
and have not as yet been accurately studied. A certain propor- 
tion of the few that seem to occur, probably depend upon hem- 
orrhage from degenerated blood-vessels in t\\? tympanic cavity. 



1 On the Etiology of Bright's Disease, with Remarks on the Prophylaxis. Trans- 
actions of the New York Academy of Medicine, vol. iii. 
- American Journal of Otology, vol. i., p. 186, 



300 VASCULAR TUMORS OF MEMBRANA TYMPANI. 



VASCULAR TUMORS OF THE MEMBRANA TYMPANI. 

Todd/ of St. Louis, reports a case of somewhat alarming 
hemorrhage from the depth of the auditory canal, after the 
puncture of a small swelling that hid the membrana tympani. 
The patient had suffered twenty -two years previously from sup- 
puration of both middle ears. As a result of this disease, his 
hearing was impaired, and he had a throbbing noise in his left 
ear. The arterial bleeding was stopped by a tampon, but it was 
renewed on removing it, and the sac filled with blood as soon 
as it was removed. Under the use of a compress of cotton mois- 
tened with glycerate of tannin, the sac was found, two years 
later, to be of a whitish color and thickened. It was about the 
size of a split pea. Dr. Todd was not able to see the membrana 
tympani in any of his examinations. It is possible that the 
hemorrhage was from a tumor of the drum-head or tympanum, 
rather than from one having an origin in the auditory canal. 

Buck 2 reports a case of vascular growth on the drum-head. 
In the posterior superior quadrant, just behind the short process 
of the malleus, was found a bright red fleshy mass, about a 
millimetre or a millimetre and a half in diameter. It was soft 
and freely movable. The patient was a lady of twenty-two 
years of age. 

I am now treating a Sister of Charity of about thirty-five 
years of age, who has an affection of the right middle ear, with 
a vascular growth in the drum-head. The patient was first seen 
in the spring of 1883, about one year since. Her symptoms were 
impairment of hearing and tinnitus. A red growth was found 
to involve the centre of the membrana tympani, and with it the 
handle of the malleus. It formed a ridge nearly across the 
whole surface of the membrane. It was of a bright red color. 
I incised it with a paracentesis needle. The tissue was rather 
hard, and although the opening was full and bled freely, the 
tumor did not fully collapse. Since then four incisions have 
been made, with relief to the tinnitus, and the tumor, although 
still existing, is quite small and is less vascular, especially at 
the lower extremity. The patient has also been treated by infla- 
tion of the tympanum. The incisions into the tumor were for- 
merly followed by more bleeding than is now experienced, and 
the patient expresses a sense of relief of the fulness in the ear 
after the paracentesis. This tumor seems to me to communi- 
cate with the tympanum. It may be a growth between the in- 

1 American Journal of Otology, vol. iv., p. 187. 

2 Treatise on the Ear, p. 372. 



VASCULAK TUMOKS OF MEMBRANA TYMPANI. 301 



tegumentary and fibrous layer. The tuning-fork is heard better 
by bone conduction. The hearing distance varies from \ to £-g, 
according as the tympanum is free from mucus. 

Buck 1 also reports a second case of vascular tumor of the 
membrana tympani. This case was seen in a lady of sixty-five 
years of age, who consulted Dr. Buck on account of a slight im- 
pairment of hearing, that had existed but for a few days. In 
the central portion of the posterior superior quadrant of the left 
drum-head was a dark colored tumor, measuring about a milli- 
metre at its base. It was not particularly sensitive. In the right 
there was a similar tumor, in a corresponding situation, but it 
was smaller. 

Weir's 2 first case of intra-tympanic vascular tumor, is very 
similar to the one of which I have just given a sketch. Re- 
peated incisions, followed by cauterizations and inflation of the 
middle ear, finally effected a cure. Weir's second case 3 was 
also greatly alleviated by incisions and cauterizations with 
chromic acid, but the patient, a colored woman, finally died of 
phthisis. She was greatly troubled by tinnitus, which was usu- 
ally relieved by a paracentesis. 

It is evident from the history of these cases that paracentesis 
or incision of vascular growths of the drum-head, or tympanic 
cavity, as well as inflation of the middle ear, are generally 
indicated. By these means we may hope ultimately to secure 
shrinkage of the growths and a return to a normal condition. 

The causes of these vascular growths are not evident to me. 
Those related by Buck appear to be of the nature of naevi, while 
those of Weir and myself seem to be consequences of inflam- 
mation of the tympanum. 

DIPHTHERITIC INFLAMMATION OF THE MIDDLE EAR. 

The origin and course of diphtheritic inflammation of the 
middle ear, are so different from what obtains in an ordinary 
acute inflammation of the middle ear, caused by cold, or even 
from this disease occurring in the course of the exanthemata. 
that I feel justified in devoting a few paragraphs to a special 
discussion of it. While assisting in the case of a child of about 
eleven years of age, who died of diphtheria, and about whose 
hearing before his illness I had accurate knowledge, T observed 
that he became very hard of hearing in the course of the diph- 



1 American Journal of Otology, vol. iii., p. 888. 

2 Ibid., vol. i., p. 120. 

3 Loc. cit. 



302 DIPHTHERITIC INFLAMMATION. 

theria which affected the fauces and nostrils. The impairment 
of hearing continued as long as he lived. It may have been 
caused, as the fuller experience of other writers shows, by sim- 
ple catarrh of the middle ears, or by the formation of a croupous 
membrane in the Eustachian tube or tympanum. 

The principal writers upon the subject of diphtheria of the 
ear are Wendt, 1 Wreden, 2 and Blau. 3 

In most of the post-mortem examinations made by Wendt, of 
diphtheritic inflammations of the ear, there was merely a co- 
incidental hyperaemia or catarrh of the tympanum, in connec- 
tion with laryngeal and pharyngeal diphtheria. 

Wreden, however, has reported 18 cases of diphtheritic inflam- 
mation of the middle ear, occurring in the course of pharyngeal 
and nasal diphtheria, complicated with scarlet fever. Diph- 
theritic inflammation generally causes great impairment of hear- 
ing when it involves the ear, according to Wreden. His report 
indicates that the internal ear was also affected in his cases, for 
the tuning-fork was not heard through the bones. The drum- 
head was half destroyed in all the cases examined by him. The 
prognosis is worse in infants than in older children. Wreden 
speaks well of leeches and douches of solutions of tannin, in the 
treatment of diphtheritic inflammation of the middle ear and 
internal ear. 

Dr. C. E. Billington, who has contributed essentially to our 
knowledge of diphtheria, by a report of a large number of cases 
to the New York Academy of Medicine, informed me, and also 
stated in a public discussion, that the ear had not, in his experi- 
ence, been affected in diphtheria, except in such cases as were 
complications of scarlatina. Billington considers the difference 
between the two diseases to be so marked, as to make it a diag- 
nostic point. He has been able to trace cases of apparently 
simple diphtheria with complicating otitis, back to a scarlatinal 
origin. He thus agrees with the observations of Wreden just 
quoted. 

Jacobi 4 states that the ear, in the same manner as the eye, 
may become affected with diphtheria by continuity with the 
naso-pharyngeal space. He says a slight swelling of the mucous 
membrane of the orifices of the Eustachian tubes in children, or 
a moderate diphtheritic deposit may close them, and hardness of 
hearing be the result. In such cases the patient not infrequently 



1 In Schwartze's Pathological Anatomy of the Ear. 

2 Monatsschrift fur Ohrenheilkunde, ]S T o. X., 1868. 

3 Berlin. Med. Wochenschrift, December, 1881, p. 729. 

4 Treatise on Diphtheria, p. 74. 



DIPHTHERITIC INFLAMMATION. 303 

complains of intense pain behind the angle of the jaw and ear. 
Jacobi also recognizes the fact, that perforation of the drum 
membrane may result from diphtheritic -inflammation of the 
middle ear. 

Wendt 1 found a tubular croupous membrane or a solid cast 
in the cartilaginous part of the Eustachian tube. Once, the 
membranous formation involved both tympanic cavities and the 
antrum and cells of the mastoid, and even covered the ossicula. 
With this exception Wendt, found only hyperemia or hemor- 
rhage in the osseous parts of the middle ear. 

Kupper 2 and Gottstein 3 also report cases of diphtheritic otitis. 
The former author gives an account of a post-mortem, in which 
it was shown, that croupous inflammation of the mucous mem- 
brane of the tympanum, and of the tube had occurred with an 
intact drum-head. 

Blau, 4 of Berlin, reports in full, a case of diphtheritic pan- 
otitis, occurring after an attack of scarlatina, upon the heels of 
which, as observed by Wreden and Billington, the diphtheritic 
pharyngitis and otitis may quickly follow. In Blau's case the 
hearing was completely gone. When he first saw his patient, 
neither the tragus nor mastoid process was sensitive to press- 
ure. A membrane was found in each auditory canal. Paralysis 
of the facial nerve and great redness of the membrane of the 
tympanic cavity soon followed. Periostitis and abscess of the 
mastoid also occurred. Blau was not able to follow the case 
to its termination. He used a douche of lime-water very fre- 
quently with good effect in the removal of the membrane. It 
will be seen, that it is a perfectly well-established fact, that a 
croupous membrane may form in the middle ear, during diph- 
theria. It is also true that the labyrinth may be involved. The 
evidence leans toward the truth of the view of Dr. Billington. 
that diphtheria of scarlatinal origin is the only form in which 
otitis occurs. The reader is also referred to the report of a case 
in the next chapter of an adult dying from meningitis consecu- 
tive to aural disease, in which a croupous membrane was found 
in the middle ear. 

Of 147 cases of deaf-muteism lately examined by me, not one 
was ascribed by the family or friends to diphtheria. It is prob- 
able that the cases of diphtheria in which severe otitis occurs, 
are generally fatal. 



1 Quoted by Blau, loo. cit. 

3 Archiv fur Ohrenheilkunde, Bd. XI., p. 10. 
3 Ibid.,Bd. XVII., p. 16. 

4 Berlin. Wochenschrift, loo. oit, 



304 DIPHTHERIA — CEREBROSPINAL MENINGITIS. 

Diseases of the middle and internal ear (panotitis — Politzer) 
occurring in the course of diphtheria, should be energetically 
treated, if the general condition allows. At any rate the mouth 
of the Eustachian tube should be freely sprayed with lime-water, 
or solutions of tannic acid, and Politzer's inflation practised, so 
that, if possible, the tympanum may be ventilated, and the tubal 
muscles kept at work. Poultices over the mastoid and in front 
of the auricle, with repeated douches of the auditory canal, are 
also to be earnestly recommended. The violence of the aural 
symptoms in diphtheria are only equalled by what occurs in 
severe cases of scarlatina, where I have seen the course so vio- 
lent in an inflammation of the tympanum, that the drum-head 
and ossicles were swept away a few hours after the first symp- 
toms appeared in the f aucial extremities of the Eustachian tube. 
Urgent as the general symptoms will undoubtedly be, those re- 
lating to the ear should not be left unrelieved if possible to miti- 
gate them. 

ACUTE DISEASE OF THE MIDDLE EAR IN CEREBROSPINAL MENINGITIS. 

The examination of deaf-mutes shows that, according to the 
testimony of their friends and attending physicians (see chapter 
on " Deaf-Muteism "), many of them became deaf while suffer- 
ing from cerebro-spinal meningitis. In my opinion, the chief 
seat of the lesion, in a majority of these cases, is to be found in 
the middle ear. I am sorry that I am seldom called to see a 
case of acute cerebro-spinal meningitis, but when I am, I advise 
the use of leeches, blisters, and mercury to combat the forma- 
tion of an exudation or purulent formation in the middle ear. If 
I may venture to advise my professional friends, who see this 
disease, accompanied by impairment of hearing or deafness, I 
would say, treat the aural affection as if it were one of acute 
catarrh of the middle ear. The prognosis as to the hearing will 
then not be altogether hopeless, although ib is usually so consid- 
ered. That the disease of the ear is commonly situated chiefly in 
the tympanum, I hope to be able to prove in the discussion of the 
causes of deaf-muteism in a subsequent chapter of this volume. 



CHAPTER XII. 

ACUTE SUPPUKATION OF THE MIDDLE EAR. 

A Consequence of Acute Catarrh. — Symptoms. — Causes — Course. — Cases of Meningitis 
Consecutive to Acute Catarrh and Suppuration. — Criticisms upon the Modern An- 
tiphlogistic Treatment. — Neurotic Cases. — Treatment and Cases. — Acute Serous 
Inflammation of the Middle Ear. 

Acute suppuration of the middle ear commonly occurs as a 
direct and recognized consequence of an acute catarrh of the 
same part. A catarrhal process is unchecked, and passes on to 
a suppurative one. In some cases the catarrhal inflammation is 
unobserved — we cannot, however, say that it does not occur — 
and the first intimation of any morbid action given by the ear is 
a discharge of pus from the auditory canal. I have seen several 
cases where the patients have assured me that the first idea 
that they had of trouble in the ear, was the moistening of the 
canal from the flowing out of the pus. An examination of the 
ear in such cases has always revealed a perforation of the mem- 
brana tympani. We probably never see a discharge of pus from 
the surface of the auditory canal, without previous intimation, 
by pain or swelling, that an inflammation of the part had oc- 
curred, while this may occur from the tympanum. It is my 
belief that the cases of sudden and painless perforation of the 
membrana tympani are nearly always preceded by some pre- 
monitory symptoms, such as pharyngitis, feelings of fulness in 
the ear, impairment of hearing, and so forth ; but that the fail- 
ure to notice them is usually to be attributed to carelessness in 
observation, and that it is to be regarded as another indication 
of the common indifference to an inflammation of the ear. when 
it is not positively painful. 

Then, again, there are cases where pain is felt long before 
the pus is discharged, but where it is mistakenly referred to 
some other part of the body, or to a neuralgia, instead of an in- 
flammation. 

It is not to be denied, however, that there are cases of acute 
suppuration of the middle ear, where the initial symptoms of 
swelling of the lining membrane of the Eustachian tube and 
20 



306 ACUTE SUPPURATION — SYMPTOMS. 

cavity of the tympanum are so quickly passed over, in a few 
hours, or even minutes, as to be practically unrecognizable. 

Such a course of the disease is frequently observed in phthi- 
sis pulmonalis, where a membrana tympani will sometimes 
break down from an accumulation of mucus behind it, and go 
on to suppuration without a trace of pain. 

The usual origin of acute suppuration is a violent one. The 
severe pain of acute catarrh is unrelieved, pus is formed in the 
cavity of the tympanum, the lining of the mastoid cells is very 
much distended, the outer surface of the process becomes red, 
tender, and painful, the head throbs, and the whole system is 
seriously disturbed. In young persons delirium occurs, and in 
all subjects, who have acute suppuration of the middle ear, 
there is general febrile excitement, and the condition of the pa- 
tient is one of intense suffering. There is probably no more se- 
vere pain to which the human system is liable, than that due to 
the distention of the little space called the cavity of the tympa- 
num by mucus, blood, serum, or pus. 

Symptoms. — The symptoms, then, of this disease are usually 
pain in the ear and head, fever, with impairment of hearing 
and tinnitus. The membrana tympani also exhibits marked 
changes in appearance. 

But the pain may be entirely absent, as we have seen, and 
yet the inflammatory process, because it is sudden in its origin, 
be fairly entitled to the adjective acute. The cases of the pain- 
less form of acute inflammation in persons suffering from phthi- 
sis pulmonalis before alluded to, are not as amenable to treat- 
ment as the more acute cases. I suppose this fact is partly to 
be attributed to the failure in the general nutrition, and also to 
the contiguity of a diseased mucous membrane, which is con- 
stantly acting as an exciting cause of trouble in the pharynx 
and Eustachian tube. 

The membrana tympani has, usually lost its naturally trans- 
parent appearance in a case of acute suppuration. It has a 
boggy, sodden, or swelled appearance, and has none of its nor- 
mal distinguishing marks — the light spot and the handle of the 
malleus. Yet this is not always the case. I have seen cases 
where the transparency of the drum membrane was almost un- 
impaired, and the accumulated pus and mucus which were 
bulging it out, could be seen through it. In one case, that of 
a young lady, I found pus not only in the cavity of the tym- 
panum, but also between the mucous and fibrous layer of the 
drum-head. The pus moved when the head was moved. She 
recovered, with perfect hearing power, and a sound membrana 



ACUTE SUPPURATION — SYMPTOMS. 307 

tympani, without an artificial or spontaneous perforation of the 
drum-head. The treatment resorted to was the use of leeches, 
a gargle, and Politzers method. There was considerable pain 
at the outset, but not the intense pain which is usually one of 
the characteristics of acute suppuration. The patient visited 
my office daily during the whole course of the disease, which 
occurred in the mild weather of spring. 

It is possible that some cases of so-called abscesses of the 
membrana tympani should be regarded as examples of limited 
suppuration in the tympanic cavity. I have not as yet seen any 
cases, where it seemed to me that an abscess was confined to 
the layers of the drum-head, without any communication with 
the cavity of the tympanum or the external auditory canal. It 
should be added, that the osseous portion of the bony canal is 
often found to be very much inflamed, in conjunction with the 
symptoms in the membrana tympani, the cavity of the tym- 
panum, and the mastoid cells. I may be pardoned for remind- 
ing the student, that it is often impossible to draw the line 
between the affections of the three parts of the ear. Their ana- 
tomical connections show that they must of necessity run into 
each other, however distinctly they may be separated in their 
origin. It is rather a predominance than an exclusive localiza- 
tion of symptoms in a part, that gives rise to an exact classifi- 
cation of disease. For example, an otitis media, in a, young 
child, may very readily and rapidly pass on to an otitis interna, 
or inflammation of the labyrinth, and give us much difficulty in 
deciding which was the original affection. Politzer has given 
the name of panotitis to these cases. 

Causes. — The causes of acute suppuration of the middle ear 
are the same as those that have been enumerated in the chapter 
on "Acute Catarrh."' The important ones are comprised in ex- 
posure to wet, draughts, and cold — inflammation of the naso- 
pharyngeal mucous membrane being the usual starting-point. 

The violent use of the posterior nares syringe in an acute 
or subacute catarrh, will also in very rare cases set up acute 
suppuration in the tympanic cavity; at least I have seen it 
do so in one instance as follows: A physician, aged twenty- 
seven, had suffered for years from chronic naso-pharyngeal 
catarrh. During the winter of 187-3. lie was attacked with acute 
coryza and pharyngitis. He had once used the nasal douche for 
a similar attack, and it caused such severe symptoms that he 
was obliged to desist from it. I was in the habit of using the 
naso-pharyngeal syringe for him at irregular intervals, in order 
to relieve the chronic nasopharyngitis from which he suffered. 



308 ACUTE SUPPURATION— CAUSES. 

On visiting him one afternoon, when he was suffering from the 
acute attack, his nostrils felt so full of secretion that he requested 
me to use the naso-pharyngeal syringe, which I did, injecting a 
lukewarm solution of chlorate of potash. The bulb of the instru- 
ment caused some gagging as it came in contact with the swelled 
wall of the pharynx. In an hour or two he was attacked with 
acute aural catarrh of the left side, which, in spite of the moot 
energetic treatment by means of leeches, went on to suppuration 
before morning. Under appropriate treatment the patient recov- 
ered, with a sound drum-head, and with the hearing power as 
great as before the attack. 

The fact has already been mentioned that sea-bathing some- 
times becomes a cause of acute catarrh. In the same manner, 
want of caution in protecting the side of the head from the force 
of the waves, or the canal, or nostrils and Eustachian tube from 
the entrance of water, may produce acute suppuration. 

Scarlet fever, measles, diphtheria, tonsillitis, bronchitis, pneu- 
monia, typhoid fever, whooping-cough, and cerebro-spinal men- 
ingitis, play an important part in the production of acute aural 
disease, and usually, except in pneumonia and cerebro-spinal 
meningitis, the suppurative form is the one first recognized, al- 
though as has been said, there is probably almost always an 
unobserved stage of the milder variety of inflammation. 

Injuries of the side of the head, and of the membrana tym- 
pani, are causes of acute suppuration of the middle ear of a very 
severe nature. This subject has, however, been discussed in the 
chapter on " Injuries of the Membrana Tympani." 

Course. — The course of acute suppuration is usually violent 
until perforation of the drum-membrane occurs ; when it gives 
way — at times w^ith quite a loud explosion — relief to the severe 
pain is usually experienced. If no measures are taken to re- 
move the accumulated pus, and to check its formation, the im- 
pairment of hearing will continue, although the pain and tin- 
nitus may be relieved, and we shall soon have a case of chronic 
suppuration of the middle ear, and the patient be liable to all 
the fearful consequences of this disease. In rare cases, pus may 
escape, however, into the Eustachian tube, and the case go on 
to resolution with no perforation of the drum-head. This is 
more apt to occur in children than in adults. 

In the worst event of all, the suppuration may extend into the 
brain or the blood-vessels. It may pass through the thin, and 
sometimes porous lamella of bone which forms the roof of the 
cavity of the tympanum, or it may go beneath into the jugular 
vein, and thus produce blood-poisoning or pyaemia. It may also 
extend to the labyrinth. 



ACUTE SUPPURATION — COURSE. 309 

The mastoid process is of course always more or less involved 
in acute suppuration, or even in acute catarrh. Its cells form, 
as the anatomy shows us, an integral part of the middle ear. 
There are probably but few, if any, cases of suppuration that are 
limited to the tympanum. Disease of the mastoid process is also 
a 'dangerous complication ; but for a full discussion of the sub- 
ject, I beg to refer the reader to the chapter upon consequences 
of chronic suppuration. Under appropriate treatment, however, 
the secretion of pus usually soon ceases, the membrane closes 
up, the hearing is restored, and scarcely a trace is seen, either 
in the anatomical structure or the functions of the organ, of the 
disease which has raged so violently. 

With a want of logic that is remarkable, some practitioners 
invite suppuration of the drum-head, in every case of acute 
catarrh, or "pain in the ear," and then declare, that nothing can 
be done for the hearing when the membrana tympani is once 
perforated. Our aim should always be to prevent or limit sup- 
puration in the ear, but if it do occur, and even if a large portion 
of the drum-head be swept away, we may usually, if the ossicula 
be left, by prompt, energetic, and patient treatment, restore it, 
and with it, the hearing power. 

It should be observed, that diffuse inflammation of the ex- 
ternal auditory canal is often a troublesome complication in the 
course of an acute aural suppuration with perforation. It is 
probably caused by the irritation of the pus in the auditory canal, 
and perhaps in some cases by the excessive manipulation for the 
purpose of cleansing the ear. Such a complication is sometimes 
embarrassing and distressing, for it protracts the duration of the 
disease very much. 

Acute catarrh and acute suppuration of the middle ear are 
exceedingly amenable to judicious treatment. There are no im- 
portant parts of the body which more certainly in the large 
majority of cases recover from serious inflammations than those 
that make up the middle ear. Indeed, it should not be forgot- 
ten, that acute catarrh and acute suppuration very often run 
their entire course, and end in perfect recovery with no especial 
treatment. Any one who is in the habit of hearing the histories 
of patients and of examining the membrana tympani, soon con- 
vinces himself that young children often recover from acute 
suppuration of the middle ear under very crude but not meddle- 
some treatment, received from nurses and parents. This be- 
comes an important consideration in the physician's treatment 
of acute inflammations of the ear, for it will lead him to a wise 
conservatism in certain cases, and a healthy skepticism as to the 
value of drugs which therapeutic enthusiasts praise so highly 



310 MENINGITIS FROM AUUAL DISEASE. 

and with which they claim to avert a suppuration process. 
There are, however, painful exceptions to the rule that acute 
suppuration of the middle ear is under proper guidance, usually 
a tractable and not fatal disease. In 1877, I attended a case in 
which meningitis followed acute purulent inflammation of the 
middle ear. Death occurred in about twenty-eight days from 
the appearance of the acute aural symptoms. 1 The history of 
the case is as follows : 

Meningitis following Acute Purulent Inflammation of the Middle Ear — Death in 
about Twenty-eight Days from the Appearance of the Aural Symptoms — Post-mor- 
tem Examination of the Brain and Temporal Bone. — On March 23, 1877, Mr. A. 

H. B , aged forty-one, whom I had treated for syphilitic iritis some two 

years before, sent for me, on account of a severe pain in the right ear. I found 
the patient, who was a well-developed man, apparently in robust health, sitting 
up, but giving evidences of great pain. The pain was referred to the depth of 
the right ear. There was a profuse discharge of blood and pus from the audi- 
tory canal ; blood predominated, however. The membrana tympani was per- 
forated. The outlines of the ossicles were not seen on account of the swelling 
of the lining membrane of the tympanic cavity and of the remains of the drum- 
head. There was some sensitiveness of the tragus and auditory canal, but no 
especial tenderness of the mastoid process. 

The patient stated that on a return from a visit to Memphis and Mobile, or 
about five days before, he had a bad cold in the head, with severe neuralgic 
pains in the same region. 

Three or four days after the "neuralgia" he consulted Dr. Eoyal Prescott, 
through whose courtesy I am able to present the history from that time. 

Dr. Prescott says, in a note to me : "Mr. B came to my office on the 

evening of March 20th, complaining of pain in the right ear, and deafness on 
the affected side. He thought that his hearing had been affected for some time 
on that side. On examination I discovered a quantity of inspissated cerumen, 
which I removed by gently syringing with warm water. ... I inserted a 
few drops of warm glycerine and morphine, put in a pledget of cotton, gave him 
an anodyne, and directed him to take a saline cathartic. He came in on the 
following morning and reported that he had passed a tolerable night, that the 
pain was somewhat abated, but had not wholly disappeared." Dr. Prescott then 
ordered an infusion of opium, and directed him to remain in the house for a 
few days. 

On March 22d, according to Dr. Prescott's note, the pain had increased, 
when hot fomentations to the ear and an anodyne were ordered. The patient 
exposed himself in a severe storm in his last visit to Dr. Prescott's office, and 
became worse. At this stage I saw the patient. I ordered the application of 
two leeches to the tragus and the warm douche every hour. My associate, Dr. 
E. T. Ely, called at nine the same evening, and found him so comfortable that 
a hypodermic injection of morphia which I had proposed was not administered. 

On the 24th, the patient was quite comfortable and free from pain, but he was 
very restless and did not sleep well. He said that his sleeplessness was not on 

1 Medical Record, July 7, 1877. 



MENINGITIS. 311 

account of pain in the ear, but on the 25th two more leeches were applied. The 
discharge from the meatus continued to be very abundant and bloody. The 
warm douche was continued, and bromide of potassium was given at night. On 
the 26th there was no pain in the ear, and no especial tenderness about it, but 
his head was very uncomfortable and restless. The patient's tongue was heavily 
furred, his pulse 96, and temperature 101°. He was sleepless and without ap- 
petite. Cerebral hypersemia was diagnosticated, and ten grains of calomel were 
ordered at 11 p.m. From the 28th to the morning of the 30th the symptoms 
were about the same. By the aid of morphia tolerable sleep was secured, but 
the patient showed great anxiety and discomfort. On that morning, at my re- 
quest, Dr. Lewis Fisher saw him in consultation, and continued to see the 
patient with me until his death. Dr. Fisher concurred in the diagnosis, and 
inasmuch as the patient had suffered from syphilis, he suggested the use of 
iodide of potassium in addition to the warm douche and morphine. On March 
31st the patient had a severe chill at noon, which lasted for an hour, and which 
was not followed by sweating. The temperature was 100° at about 12 noon ; 
at 9| p.m., 103|°. The patient stated that he never had had a malarial attack, 
although he had spent much of his life in a malarious country. The formation 
of pus was supposed by Dr. Fisher and myself to be indicated by this chill. 
There was, however, no tender spot about the ear, and there seemed no chance 
of getting at the abscess, if one was forming. There continued to be a free dis- 
charge from the meatus. We therefore decided to administer quinine, as an 
antipyretic. We accordingly gave him twenty grains of sulphate of quinine and 
thirty grains of bromide of potassium, following it up in four hours after with 
fifteen grains of quinine. On April 1st the patient appeared much better. His 
temperature was 98°, his pulse 72, and there was no pain in the ear, and scarcely 

any in the head. The quinine treatment was kept up. Mr. B began to sit 

up and converse on business matters, and became very cheerful, although we 
had given him a gloomy prognosis immediately after the occurrence of the chill. 
He did not, however, sleep quite as well as a convalescent should, and on April 
12th he suddenly complained of severe pain in his right knee-joint, and his tem- 
perature ran up to 103^°. He slept scarcely at all ; he also complained of pain 
in his head, which was not localized. The discharge from the ear diminished 
very much. The pain in the knee disappeared in about twenty-four hours, and 
occurred with great severity in the back and left thigh. The mastoid process 
was cut down upon on the 9th or 10th, but no disease of the bone or periosteum 
was detected. On the 15th the temperature was 103i°, the pulse 84, and a low 
muttering delirium occurred at intervals. Professor John T. Metcalfe saw the 
patient on this day, and gave his opinion that it was a case of cerebral disease 
extending from the ear, and although he regarded the ju*ognosis as very un- 
favorable, suggested the use of mercurial inunctions and iodide of potassium, 
with a very faint hope that syphilis was causing some of the symptoms. On the 
16th the patient was scarcely ever conscious, his temperature continued at 104° 
to 104^°, and on the morning of the 17th he quietly died. 

The autopsy was made by Dr. W. D. Spencer, live and one-half hours after 
death. 

Head.— The bones, except the right temporal bone, were normal. The dura 
mater was normal. The sinuses were tilled with dark, soft ooagula. 

Brain. — The vessels on the surface were markedly hvponvmie. The vessels 
at the base appeared normal. In the meshes of the pia mater, most markedly 



312 MENINGITIS FROM AURAL DISEASE. 

at the base, and equally on both sides, v%-as seen quite an extensive fibrino-piiru- 
lent exudation, which was thicker along the course of the larger vessels : this 
exudation extended anteriorly to the surface of the right hemisphere, when it 
was more sera-purulent. The lateral ventricles were markedly dilated and filled 
with blood-stained serum. The brain substance was firm and markedly hyper- 
femic. otherwise normal as far as examined. The connective tissue posterior to 
the external ear and coating the mastoid bone was somewhat cedematous. (This 
the site of the incision down to the bone, an incision that was kept open 
.-- 

Description of the temporal bone : 

Mastoid. — There are two discolored spots on a line running outward from the 
meatus auditorius extemus. 

Petrous portion. — -Just in front of the elevation made by the semicircular 
canals the bone is exceedingly soft. In washing it was broken down, and the 
whole structure here, or the roof of the tympanic cavity, is found to be in a 
state of ulceration. An ope ni ng through the squamous portion of the bone, or 
in the temporal fossa would be about on a line with this ulcerated point. 

1 ; «. — The bony wall of this venous canal is lisooloied, thinned, 

and softened Throughout about one-half its extent. 

2V - — The ossicula are intact, but :Lt whole :: the membrana 

tympani is gone. 

We are all familiar with cases of meningitis resulting from 
disease of the middle ear of long standing, but cases of this 
kind following acute aural disease are fortunately more rare. 
Indeed, vre generally expect to subdue an acute inflammation of 
the ear. if we are able to treat it antiphlogistic ally within a few 
days of the outbreak of the disease. Nowhere does rational 
therapeutics avail more than in acute affections of the ear. In 
this case there was never a discharge from the ear. according to 
the patient's statement, until a few hours before I saw him. 
The affection began as an acute otitis media catarrhal is. with 
impaction of cerumen, which the patient, until corrected by Dr. 
Prescott. thought was a facial neuralgia — a not uncommon, but 
dangerous error. It ran a violent course, as is shown by the 
bloody discharge and great pain. 

The purulent process in the middle ear extended to the tissues 
of the roof of the tympanic cavity, and to the labyrinth and 
the membranes of the brain, where the hypersemia soon became 
an exudative inflammation of the base, extending very slowly 
to the upper surface, and consequently leaving the intellect un- 
impaired for a long time. The disease of the bone went on 
5] wly at the same time. The pyaemic symptoms are explain 
by the disease of the lateral sinus. The circumstances of the 
patient — for he lived in a crowded boarding-house — were not 
favorable to the quiet that should always be secured for a pa- 
tient with cerebral hypersemia, and I fear that I did not lay 



MENINGITIS. 



313 



stress enough upon this requisite in the first few days. My sus- 
picions as to cerebral hypersemia were somewhat lulled, how- 
ever, during the first forty-eight hours, by the fact that the pain 
in the ear nearly entirely disappeared from the first application 
of the leeches. The only part of the case that now seems ob- 
scure to me, and in this opinion Dr. Fisher agrees, is the reduc- 
tion of the temperature, and the great improvement in the gen- 
eral condition immediately after the use of the large doses of 
quinine. We gave quinine, as has been intimated, on the 
shadow of a hope that we were dealing with a severe case of 




Fig. 82. — Showing Disease of Bone in Case of Meningitis following Acute Suppuration of 
the Middle Ear. a, Caries in front of elevation for semicircular canals ; b, caries of lateral 
sinus ; e, meatus auditorius internus. 



malarial fever, instead of one of abscess of the brain or inflam- 
mation of the meninges. With a diagnosis of either of the 
latter-named, we had simply to sit down with folded arms and 
await the dissolution of the patient. The reduction o( the tem- 
perature immediately followed the administration o( the quinine, 
and each day, as it showed a disposition to rise, the same rem- 
edy seemed to lower it, until the septicsemic pains set in, when 
it utterly failed. Indeed, so well was the patient for about a 
week, that Dr. Fisher and I were inclined to change our original 
diagnosis. Such a lull in the symptoms of cerebral disease re- 



314 MENINGITIS FROM AURAL DISEASE. 

suiting from an inflammation of the ear, is, however, not with- 
out precedent. 

There was always an unbroken bone between the ulcerated 
tympanic cavity and the membranes of the brain, so that the 
fatal inflammation must have extended through some of the 
small foramina, which abound in the temporal bone. This is no 
new pathological observation, since it has long been known, al- 
though not always remembered, that we may have meningitis 
as an extension of aural disease without the occurrence of 
caries. 

Another case of this unfortunate series was reported by Dr. 
C. S. Merrill, 7 of Albany, K Y. Death occurred on the fourth 
day after the origin of the acute inflammation of the middle ear. 

The patient was a book-keeper, temperate and regular in his habits of life. 
He had always been well, but for two or three weeks he had been a little debili- 
tated from overwork. On November 7, 1877, he noticed for the first time a ful- 
ness in his right ear. He consulted his family physician, who sent him to Dr. 
Merrill. The membrana tympani was found congested, and the hearing on that 
side impaired. The ear was inflated by Politzer's method, and the family phy- 
sician was advised to apply two leeches to the ear. Dr. Merrill did not see the 
case again for two days, when Dr. Bigelow sent for him. It was then stated that 
the leeching had entirely relieved the condition, so that all feelings of fulness 
passed away, and the hearing became normal. The patient, contrary to Dr. 
Bigelow's advice, resumed his office duties. But on the 9th, at 5 o'clock in the 
morning he was attacked with severe pain, and Dr. Bigelow was sent for on the 
next day at noon and found the pulse 160, temperature 103^°, respiration 28. 
The patient was delirious. The membrana tympani was bulging and greatly 
inflamed. A free incision of the membrane, which was thick and resisting, 
evacuated a large amount of pus. The next day the local inflammation had 
greatly subsided, but coma supervened, and death occurred four days from the 
first manifestation of aural symptoms. The post-mortem examination showed 
meningitis. " Pus was found over the region of the petrous bone." There was 
perforation through the roof of the middle ear, and underneath the dura mater 
and covering the surface of the brain there were a few drops of greenish-colored 
pus. The bone was perforated by two or three small openings. There was no 
evidence of inflammation of the internal ear. 

Dr. Merrill remarks : "The fatal termination of the case was 
evidently due to the direct extension of the inflammation to the 
membranes of the brain through the roof of the middle ear, 
which in this patient was cribriform in appearance." 

I also saw, in consultation with Dr. Loring, a case in which 
death from meningitis occurred after a few days of symptoms of 
acute inflammation of the middle ear. This patient, however, 
had had sub-acute catarrh of the middle ear at various times dur- 

1 Transactions of the American Otological Society, vol. iii., p. 29. 1882. 



MENINGITIS. 315 

ing the two years preceding the attack which terminated fatally. 
It was not a suppurative case. Dr. Welch, who made the post- 
mortem examination, regarded it as a croupous inflammation 
of the middle ear. I was present when Dr. Loring made a large 
free opening in the membrana tympani, and found that it con- 
tained no secretion. The dura mater was normal except in one 
situation. That over the roof of the tympanic cavity and the 
adjacent portion of bone, was very much congested and showed 
" numerous small red points, which represent punctate hemor- 
rhages." The roof of the tympanic cavity was found extremely 
thin and translucent, but "it was not carious. The mucous 
membrane of the middle ear was found swelled, softened, of a 
bluish-red color, and coated in many places ivith a reddish-gray 
opaque false membrane, averaging about one millimetre in thick- 
ness. Punctate ecchymoses can be seen in the swollen mucous 
membrane, but there were no coagula of blood in the cavity of 
the tympanum." The swelling and exudation were most marked 
on the membrane of the roof of the tympanum, on the promon- 
tory and entrance of the Eustachian tube. There was also exu- 
dation in the osseous portion of the tube. The ossicles were 
movable, the labyrinth and auditory nerve were sound. There 
was no fibrinous exudation in the pharynx, fauces, or air-pas- 
sages. After a microscopical examination Dr. Welch, gave as 
his opinion that the case had been one of otitis media crouposa 
with consecutive septo-meningitis. The * ' consecutive " was prob- 
ably placed somewhat in doubt, because at the post-mortem ex- 
amination it was not easy to trace the starting-point of the men- 
ingitis of the convexity of the brain from the right middle ear. 
The yellowish sero-purulent exudation in the sub-arachnoid 
space and meshes of the pia mater covering the convexity of 
the cerebral hemispheres, "was rather more abundant upon the 
left than the right side." ! 

Added to these exceptional cases of death from acute inflam- 
mation of the middle ear, is that of a young man, who was 
attended by my associate in private practice. Dr. Edward T. Ely, 
with whom I saw the patient in consultation, who died in a few 
days from consecutive meningitis, without rupture of the mem- 
brana tympani. His first symptoms were from the oar. and 
there were objective appearances of acute inflammation of the 
middle ear. Symptoms of meningeal hyperemia wore very early 
in appearance, and in spite of active treatment he soon died in a 
comatose state. No post-mortem examination was made. 

The reader will observe that the thinness of the bone forming 



1 American Journal of Otology, vol. in., p. I0o. 



316 ACUTE SUPPURATION— TREATMENT. 

the roof of the tympanic cavity was marked in two of the fore- 
going cases. As has been pointed out by all the recent writers 
on aural surgery, this anomaly is not uncommon, and where it 
does exist, it must cause a peculiar susceptibility to consecutive 
meningitis from disease of the middle ear. Since we can never 
know beforehand in which cases this anomaly is found, and while 
we do know, that in young children the bone is always thin and 
porous, we may on reflection realize the possible serious char- 
acter of any case of acute disease of the middle ear. 

I can add another case of death from acute suppuration of the 
middle ear, which occurred in my practice at the Manhattan Eye 
and Ear Hospital. In this case, however, the rational treatment 
was undertaken some days after the disease had fully set in, 
and it is also altogether likely that the fatal termination was 
hastened by the patient's bad habits. I first saw the young man, 
who was the victim in this case, when he was pale and haggard 
from pain and sleeplessness. The drum-head was bulging. I 
punctured it and evacuated considerable pus. This gave great 
relief, as he told me two days later, when he again appeared at 
the clinic. His whole aspect was much better, and he told me 
that he had slept well for two nights. He died in a few days, 
just after a drunken debauch. The physician who saw him 
informed me that he died from meningitis, consecutive to the 
aural trouble, but I was not able to get an exact account of the 
lesions, although the death was investigated by the Coroner, 
and an attempt was made by some of the patient's friends to 
prove that his death was caused by the operation (paracentesis 
of the drum-head), which secured him the first sleep he had had 
for some days. The most appalling evidence was given to show 
that the "Doctors murdered him by running an instrument into 
his brain." ' 

Treatment. — The moral of the foregoing is plainly to be read. 
An acute catarrh or suppuration of the middle ear should never 
be lightly estimated. A case seen early in its course will usu- 
ally prove very tractable and respond readily to treatment, but 
if left to itself it may be a serious case. The first step in the 
treatment is to insure quiet and freedom from care for the pa- 
tient, if an adult. Patients with acute suppuration should usu- 
ally be confined to their rooms. If adults, absolute freedom 
from business or domestic employment should be insisted upon. 

1 The medico- legal reader, may possibly be interested in the verdict given by the 
Coroner's jury in this case. The following is a copy of it: "We the jury come to the 

conclusion that came to his death by a rupture of the blood-vessels of the small 

brain or with some instruments used by doctors unknown to the jury." 



ACUTE SUPPUEATION — TEEATMENT. 317 

Each case should be watched as forming a possible starting- 
point for cerebral meningitis. In the large majority of cases 
such a deplorable consequence will not occur, but it would, I 
think, be much less frequently observed, were each patient with 
acute suppuration carefully guarded from the exciting causes 
of cerebral hypersemia, from the beginning of the aural disease 
until he is fairly convalescing. The room, or ward in which 
such a patient is, should be kept free from visitors, prolonged 
conversation, bright light, noise should not be allowed, and an 
attempt should be made to secure physical and mental quiet. 
To underrate the gravity of an acute suppuration, or even an 
acute catarrh of the middle ear, is to invite peril to life. 

I have seen at least two cases where, I believe, the life was 
lost, because the patients insisted that a painful ear and a ten- 
der mastoid process, were not sufficient causes to keep them 
away from business and from active social life. 

If the case be seen in the earlier stages — that is, when the 
pain is still present, and the membrana tympani is intact — two 
or more leeches should be at once applied, and if the appearance 
of the membrana tympani indicate that it is about to rupture, 
or if the pain be not quickly subdued by the use of the leeches, 
a paracentesis of the membrana tympani should be at once per- 
formed in the most bulging portion of the membrane. If the 
mastoid be red, tender, and swelled, it should be poulticed thor- 
oughly and well, and if relief be not apparent in twelve hours, 
it should be incised down to the bone, except in the case of 
young children, where the more yielding nature of the integu- 
ment and the periosteum will admit of some delay. If the mas- 
toid process be simply red and tender, but not swelled, the use 
of leeches and poultices will probably subdue the inflammation 
without an incision. 

The ear should be douched very often, say every half hour, 
with lukewarm or hot water, by means of a fountain syringe or 
the Fayette douche, the temperature of the water being deter- 
mined by the patient's feelings. This procedure the patient will 
usually find very grateful. In case of the absence of a douche, 
warm water may be dropped into the ear from the sponge, a 
procedure as old as the time of Hippocrates. A douche may be 
extemporized by the syphon arrangement of a bit of rubber 
tubing in any kind of a vessel that will contain water. At the 
same time, especially if the weather be cold, the patient should 
be kept in his room, and perhaps in bed, while pediluvia ami 
diaphoretics are employed. 

If the membrana tympani have ruptured, the pus should be 
removed at least twice a day, by careful but thorough syringing. 



318 ACUTE SUPPURATION — TREATMENT. 

The quantity of pus discharged is sometimes enormous. At 
the same time, Politzer's method of inflating the ear should 
be practised. This latter procedure gives no pain when care- 
fully done, i.e., when the bulb is not too vigorously pressed. It 
at once improves the hearing, helps to cleanse the ear, and pre- 
vents the formation of adhesions in the cavity of the tym- 
panum, and gives the patient hope and confidence. 

The throat should be kept free of secretion by a gargle. The 
chlorate of potash in a saturated solution is the one I usually 
use. In cases of scarlet fever, the pharynx will require the 
most careful and energetic treatment. The neck should be kept 
warm by poultices, and the pharynx be very often cleansed by 
the use of a nebulizer, chlorate of potash in powder placed upon 
the tongue, and so forth. Dr. Sexton, of this city, has found 
great relief in tonsillitis from the use of the warm douche upon 
the pharynx, by means of Davidson's syringe, or rubber tubing 
attached to a water-faucet, and I have confirmed this experi- 
ence. 

Relapses of pain should be combated by leeches, warm water, 
and the internal administration of opium, or morphia, chloral, 
and bromide of sodium combined ; but opium has very little 
power in subduing the pain from acute aural suppuration, if 
used without the local treatment. The administration of calo- 
mel or other mercurials, the application of blisters, will not be 
required. The former kind of treatment is useless, while the 
latter aggravates the suffering of the patient. Blisters are more 
applicable to chronic aural disease, but in the absence of leeches 
they are useful. 

If the case go on well, a physician who does not see much 
of this form of disease, will be astonished at the rapidity with 
which the suppuration is checked, and the membrana tympani 
restored. The impairment of hearing will be the last symptom 
to be fully relieved. The hearing power should be often accu- 
rately tested by the watch and tuning-fork in the course of the 
disease, in order that if possible we may not dismiss the patient 
until the cure is complete. 

The astringent that I usually use in acute suppuration is a 
solution of sulphate of zinc, which is poured into the ear once or 
twice a day,' after syringing. The solution should be previously 
warmed. Should the suppuration continue unduly, the nitrate 
of silver may be applied in strong solutions, say from forty to 
eighty grains to the ounce. This solution is brushed over the 
drum-head and in the edges of the perforation. In some cases 
it may be necessary to drop the solution into the ear, afterward 
neutralizing it by syringing with a warm solution of salt and 



ACUTE SUPPURATION — TREATMENT. 319 

v/ater. Indeed, it should be said once for all, that, except in very 
rare and exceptional cases, cold fluids should not be dropped 
into the ear. 

I do not begin the use of astringents in the treatment of acute 
suppuration, until I have assured myself by careful trial, that 
the cleansing of the ear is not of itself sufficient to cause the 
purulent discharge to cease. In many cases I never have occa- 
sion to use an astringent, but the curative influence of nature, 
impediments to her action being removed, proves to be sufficient. 
Br. Ely, who was for years associated with me, both in private 
and public practice, called attention to this subject, 1 and pub- 
lished some cases from our practice which I here insert as being 
of great illustrative value in discussing this subject. 

Dr. Ely remarks that "great labor has been required to lead 
physicians and laymen- to consider acute suppuration of the 
middle ear as of any importance, and it is natural that many 
practitioners having thus been laboriously awakened to its im- 
portance should hold exaggerated ideas as to the remedies re- 
quired for its cure." 



CASES OF ACUTE SUPPURATION OF THE MIDDLE EAR TREATED WITH- 
OUT ASTRINGENTS. 

Case in which the Use of an Astringent aggravated the Symptoms. 

Miss H , aged twenty, consulted me November 30, 1877, with acute sup- 
puration of her left middle ear of ten days' duration. There was a free discharge 
of pus, and no pain or swelling. I ordered syringing of the ear, and the instilla- 
tion of a two-grain solution of sulphate of zinc twice daily. Immediately after 
using the zinc-drops she began to have violent pain in the ear. This pain con- 
tinued all night, and, when I saw her the next day, the auditory canal was so 
swollen that the drum could not be seen ; the whole of that side of the face was 
swollen and tender, and there was congestion and pain in the eyeball. There 
was a temperature of 101° and some vertigo. Leeches, hot water, morphine, 
and rest in bed were prescribed. The pain, swelling, and vertigo did not dis- 
appear until the evening of December 4th. I always attributed this attack to 
the effect of the zinc, although I have no further proof of the fact than the 
patient's own belief of it, and the history of the case. 

Cases in which no Astringents were Used. 

I. — Susie M , aged six, came on November 11th with a history of pain in 

her left ear from G o'clock until 11 of the previous evening. The drum-head 
was found congested and ruptured, and there was a purulent discharge. Syr- 
inging of the ear with warm water twice a day was ordered. On the 14th 
there was no discharge, and the perforation seemed to be healing ; the syringing 
was discontinued. On the lOth the perforation had healed and the hearing was 

1 Archives of Otology, vol. viii., p. 17;>. 



320 ACUTE SUPPUEATION — TEE ATM EXT. 

fully restored. II. — Miss J. H , aged twenty-one, came on March 11th, hav- 
ing had severe pain in her left ear since 3 a.m. The drum-head was found rup- 
tured, and there was purulent discharge. The hearing on that side was - 4 %. 
Leeches and the hot douche were ordered, and they seemed to arrest the pain 
at once. After that, the ear was simply syringed occasionally with warm water. 
On the 13th the perforation was nearly closed. On the 18th it was completely 

healed, and the hearing was $%. III. — Mrs. M , aged thirty-five, came on 

March 17th, saying that she had had a cold in her head for the past week ; that 
two or three days ago, while blowing her nose, she had felt a "cracking" in her 
right ear, and that since then there had been a discharge from the ear. Before 
this trouble the drum-head on that side was cicatricial from a suppuration in 
childhood. A large perforation was found in the posterior part of the drum- 
head, with a rnuco-purulent discharge. The hearing was -&. Syringing with 
warm water, two or three times a day, was ordered. On March 19th the perfo- 
ration was much smaller ; the discharge was still abundant. On March 20th 
there was no discharge. The next day her cold became worse, and she had 
some fever. The following three days she had throbbing and tinnitus in the 
right ear with reappearance of the discharge; also had some vertigo. Was 
taking quinine during this time. On the 25th the discharge had ceased, and a 

few days later the perforation was healed. Hearing - 4 %. IV. — Mr.W , aged 

forty, came on February 24th with a broken dram-head and acute suppuration, 
in the right middle ear. The discharge had appeared on the 19th, after eight 
hours of pain in the ear. Syringing with warm water was prescribed. On 
February 27th, the discharge was found to be less. On March 2d, the discharge 
had ceased and the perforation was very small. A few days later, the drum-head 

was found to be healed and the hearing restored. V. — Master L , aged five, 

came June 17th with a history of earaches, both sides, for the previous four 
weeks. An examination showed perforation of both drum-heads and acute sup- 
puration of the middle ears. No treatment was employed except syringing with 

warm water. The patient made a perfect recovery. VT. — Master F , aged 

fourteen, came on April 7th with acute suppuration of the left middle ear. The 
use of the warm douche was prescribed. On April 17th the ear was doing well, 
and the hearing was ju- A few days after this the patient was cured. 

In this case and the preceding one the exact date of recovery 
was, unfortunately, not recorded. 

VII. — Miss M , aged eighteen, came on December 14th with acute sup- 
puration of the right middle ear, of a few days' duration. She had already had 
a chronic suppuration of that ear, following measles, which had been checked, 
without restoration of the drum-head. Warm syringing was prescribed. On 

January 14th the discharge was found to have ceased. VIII. — Master V , 

aged sixteen, came on June 20th with an acute suppuration of the left middle 
ear. The discharge, which was very bloody, had been noticed by the patient a 
day or two previously, after a night of very severe pain in the ear. There had 
already been marked deafness on both sides, from chronic catarrh, for many 
years. The only treatment prescribed was syringing of the ear with warm 
water two or three times a day. On June 27th the drum-head was found to be 
healed. There had been no discharge for several days. 



ACUTE SUPPURATION— TREATMENT. 321 

The local treatment in all these cases, consisted simply in 
syringing the ear with warm water as often as seemed advis- 
able. Of course, the throat and the general health received 
attention when it seemed to be required. 

Criticisms upon Local Antiphlogistic Treatment in Aural 

Disease. 

Papers have been written, containing elaborate arguments 
against the use of leeches, Wilde's incision down to the perios- 
teum of the mastoid, and other active forms of treatment of 
acute aural disease, as if the writers who advised these means 
in cases of necessity, always found them necessary. The crit- 
icisms upon active treatment in acute aural disease have not 
always been discriminate, for they have sometimes assumed 
that the modern writers advised the use of the leeches and the 
knife in all cases, and that they prescribed a routine treatment 
without using their judgment as to each individual case. I am 
of the opinion that the use of leeches, paracentesis of the drum- 
head, and incision of the mastoid, have all the importance that 
has been ascribed to them by. modern otologists, yet I have 
never failed to counsel circumspection in the prescription of 
active means of treatment. I have as yet found no means of 
internal treatment, that will supersede active antiphlogistic 
means, such as leeching and incisions of the membrana tym- 
pani in severe cases of acute disease of the middle ear. There 
are many mild cases, however, even of this form of diseases, 
or cases of an asthenic type. In these the surgeon will soon 
find that a quiet room, the warm douche, diaphoresis, and so 
forth, will often be sufficient with no more active means. As 
an example of cases of acute aural disease which require 
constitutional rather than local treatment, even when local 
symptoms are markedly manifest, the following case heretofore 
published 1 is inserted. It is a striking example of a neurotic, 
rather than an inflammatory case, a variety which the physician 
should always be on the look-out for, among hysterical women 
and overworked men. 

Acute Inflammation of the Middle Ear, with Inflammation of the Muscles of the Neck, 
and Facial Paralysis of the Same Side. 

May 5, 1879. — Dr. S , aged forty-five, a busy surgeon and medical jour- 
nalist, consulted me in regard to uncomfortable and painful sensations in his 
right ear. He was somewhat anaemic, jaded from overwork, and he had an 
anxious appearance. He described the pain as extending from the right Eus- 

1 Archives of Otology, vol. viii., p. 055. 
21 



322 LEUKOSIS OF MIDDLE EAE. 

tachian tube to the drum, laying great stress upon the pain along the tube. 
The drum-head was red, the auditory canal normal. There was nothing marked 
about the pharynx. The hearing distance was not noted. Leeches were or- 
dered to be applied to the tragus. I afterward learned that he had slight nasal 
catarrh and headache with pain in right lower jaw, on May 4th. The next day 
I received a note from the patient stating that he did not feel able, on account 
of the pain, to come to my office, which was a very short distance from his. I 
found him in bed and apparently suffering very much. He complained of a 
pain like that from neuralgia, extending over the right side of the scalp, face, 
neck, the right auditory canal, and the Eustachian tube. Leeches and the hot 
douche were prescribed. The patient then told me that he had suffered very 
severely a few weeks before from facial neuralgia ; that he then had no aural 
trouble ; that he had had very lately an inflammation of the muscles of the op- 
posite side of the neck. The membrana tympani was vascular, but not bulging. 
Knowing that this patient had been very much overworked, with an insufficient 
quantity of fresh air, and seeing that he was pale and hyper-sensitive, I con- 
sidered the pain as out of proportion to the objective symptoms of inflamma- 
tion, and I therefore made a diagnosis of non-suppurative inflammation of the 
middle ear, with neuralgia of the fifth nerve. In other words, I believed that 
the otalgic symptoms predominated over those of true inflammation. Warm 
applications behind and over the ear were advised, as well as the use of the 
hot douche. The hot douche was not well borne, nor was there much relief, 
except at short intervals, from these measures. It should also be said that I 
laid great stress upon maintaining the nutrition, and a generous diet was in- 
sisted upon. On the fourth or fifth day the auditory canal was somewhat 
swelled, but not tender. I incised the drum-head, but no pus or mucus was 
evacuated. The hot douche was now freely used and afforded relief. A very 
moderate suppuration occurred in the tympanic cavity. Morphia was adminis- 
tered, pro re nata. The patient sat sometimes out of bed, but did only tolerably 
well, complaining at intervals of very severe neuralgic pain which was relieved 
by morphia. He took nourishment badly, except in the intervals of freedom 
from pain. He was very much depressed in spirits. There was no tenderness 
or any other inflammatory symptoms on the mastoid or in the pre-auricular 
region. On May 15th — ten days after I first saw the patient— I went out of town 
to fill a professional engagement, and my associate, Dr. E. T. Ely, took charge 
of the case until May 25th, and his notes are as follows : 

"Dr. S seems to be a case of acute suppuration of the middle ear, with 

considerable swelling of the auditory canal ; slight discharge ; no pain. 

"May 16th. — More pain and swelling; no discharge. 

"May 17th. — Severe pain in whole right side of face and head and in the ear, 
not controlled by douche ; no discharge ; funnel-shaped swelling of the canal, 
not very tender. Consultation with Dr. A. H. Buck. It was decided to incise 
the canal and reopen the drum-head. This was done under ether. The open- 
ing in the drum-head was very free, and the canal was incised from the bottom 
to the entrance. Thuee leeches were then applied to the tragus and one to the 
mastoid. Hot douche was continued. No pus followed these incisions. 

"May 18th. — Pain most of last night. A little easier this morning. Dis- 
charge of pus beginning. 

"May 19th. — Comfortable until evening, then great pain in ear and head; 
temperature, 101^°; three leeches to mastoid ; douche; morphia. 



NEUROSIS OF MIDDLE EAK. 323 

"May 20th.— Not much pain ; weak and depressed, a.m.: Temperature, 98fc° ; 
pulse, 88 ; p.m.: temperature, 100^° ; pulse, 88. Slept most of the day. 

' ' May 22d. — No fever yesterday or to-day ; one attack of severe pain last 
night ; canal red and swollen ; free discharge since incision ; four leeches ap- 
plied, and hot douche, for twenty minutes every two hours. 

" May 24th. — Pain part of every day, no fever; severe pain last evening qui- 
eted by morphia ; slight mastoid tenderness and oedema last evening and this 
morning ; less swelling in canal. Dr. Buck was again called in consultation ; he 
advised opening the mastoid by trephining. Dr. O. K. Agnew was called in the 
afternoon. He considered the case a typical one of mastoid disease of prolifer- 
ous nature, but that no suppuration was going on there. He thought the dis- 
ease was chiefly in the mastoid from the outset, and that there was meningeal 
congestion. By the ophthalmoscope the veins in the right fundus seemed a 
little fuller to Dr. A. and to Dr. Ely than in left. 

May 25th. — Very slight oedema and some tenderness over mastoid, and al- 
though only one dose of the iodide of potassium prescribed the day before was 
taken, iodism was produced. Patient was awake all night from sneezing, and 
had some pain in the other ear. He is nervous and hysterical, buries his head 
in the bedclothes, and refuses to be comforted. He expresses the belief that he 
will not recover. On this date I met a gentleman with very large aural experience, 
and we went over the case very carefully. The patient seemed to be suffering very 
much, and he located the seat of his pain by spreading out his hands like a fan 
over the right side of the head. The tenderness about the ear was not very great, 
and was found in the neck and occiput as well. The ear was discharging freely 
with healthy pus. The mastoid was so slightly cedematous that I thought its 
condition might be due to the leeches and other applications. It did not seem 
to me to be a case of mastoid periostitis, nor did I think there was any meningitis 
or cerebral disease. Although I did not feel so sure of the former point as of the 
latter, I still thought the pain was neuralgic rather than inflammatory. Inasmuch, 
however, as Dr. Agnew had on the day before given the opinion that the mastoid 
was markedly involved, and that there was a meningeal hyperemia, and as the 
gentleman now in consultation was much more decided in the opinion that the 
mastoid was the point of the origin of the pain, and moreover, since my own 
judgment was a little doubtful and wavering, I advised that a Wilde's incision 
be made at once. If this incision failed to detect disease of the bone, I resolved 
to take no further operative steps at this time, although the gentleman in con- 
sultation afterward stated to me, that he considered this but a step in the right 
direction, he believing that the bone should be opened, and that even if no pns 
were found, the bone-fistula would do no harm. The incision was accordingly 
made ; no disease of the bone was found. The wound was dressed to the bot- 
tom with lint, and a poultice was applied. 

May 28th. — The pains in the head and neck are not at all relieved except 
when morphia is used in full doses. The tissues of the mastoid, pre-auricular 
region, and neck were red, swelled, and tender at various points. These symp- 
toms have increased since the incision. The depression o( spirits continues, but 
at times the patient can be made quite cheerful by light conversation, and after 
a dose of morphia. He is taking a moderate amount o( stimulants, and milk 
quite freely. Dr. William A. Hammond was called in consultation: his opinion 
was that there was no disease in the cranium, and that the pain was due to neu- 
ralgia largely modified by malaria, lie advised that 60 gis. of quinine be given 



324 neueosis of middle ear. 

in twenty-four hours, for two days, and that this treatment be followed up by 
small doses of arsenic. This treatment was followed by an apparent alteration 
of the pain, and not so much morphia was needed. 

On June 3d the muscles of the neck were so much swelled that we pronounced 
them in a state of inflammation, and leeches were applied. The arsenic and 
generous diet, as far as patient would take it, with moderate doses of alcohol, 
were continued. The neck was especially tender where nerves made their exit. 
There was no especial tenderness on the mastoid; the patient could scarcely 
move his head from side to side. 

June 7th. — The conjunctiva and outside of lids of right eye are reddened ; 
the ability to close the right eye is impaired. 

June 8th. — Conjunctiva and lids less red than yesterday. Slight enlargement 
of gland at the angle of the jaw on right side. Severe pain in the jaw and mas- 
toid region. Morphine was freely administered hypodermically for its relief. 
A poultice was kept on the side of the face and the head. Temperature, 10LJ° ; 
pulse, 100. 

June 9th. — Swelling at the angle of the jaw increased ; pain severe, and facial 
paralysis on the right side well marked. The right lid does not completely close 
in winking. The right side of the face appears rounder and fuller than the left, 
and the mouth is slightly drawn toward the left. The tongue protrudes in a 
direct line, and there is no deviation in the uvula. There is apparently no dis- 
turbance of the sense of smell. Temperature, 99|° ; pulse, 94. Two leeches 
were applied behind the ear. p.m.: Severe pain; TTL x. of Magendie's solution 
every three hours (hypodermically). 

June 10th. — a.m.: Temperature, 98£° ; pulse, 100. Slept well; took about 
one quart of milk during the night. Facial jtaralysis increased. Ophthalmo- 
scopic examination by Dr. Eoosa. The appearance of the fundus is the same in 
both eyes, and nothing abnormal is seen in either. The ear discharges freely. 
p.m.: Longer intervals of freedom from pain. No morphine since the 8th at 

9 P.M. 

June 11th. — a.m.: Temperature, 99|°. Swelling at the angle of the jaw dimin- 
ished. No pain since June 10th at 9 p.m. p.m. : Pain recurs ; not so severe. 
Chloral and bromide of sodium are given for its relief. 

June 12th. — a.m.: Patient slept badly. Pain returned in the old regions, the 
jaw, behind the ear, and over the right side of the head. Temperature, 98|° ; 
pulse, 91. Patient very much depressed in spirits. Morphia again administered. 
At 5 p.m. a consultation was held, at which were present Dr. Alfred L. Loomis, 
Dr. Henry B. Sands, Dr. Charles B. Briddon, Dr. \V. M. CariDenter, and the 
attending physician, Dr. Boosa, After Dr. Boosa's statement that the pus was 
freely discharging from the auditory canal, and that, in his opinion, there was 
no retained pus in the bone, without claiming to decide the strictly aural points 
of the case positively, the conclusion was reached by the consulting surgeons 
and physicians that the patient had no symptoms of intra-cranial trouble ; that 
there was no indication for operative interference with reference to the mastoid 
process, or suppuration in any part of the neck ; that supporting treatment was 
demanded. On the suggestion of Dr. Loomis the stimulant he was receiving 
was increased to 1^ oz. of whiskey every three hours, and pushed to 2 ozs. as soon 
as it became evident that it did not disagree with his stomach. 

June 13th. — Patient feels very comfortable ; has slept well ; is taking 2 ozs. of 
whiskey in a tumbler of milk every three hours, and has not experienced the 



NEUROSIS OF MIDDLE EAR. 325 

slightest intoxicating effect. Takes nourishment aside from the milk. Temper- 
ature, 99° in the morning, 98|° 6 p.m. ; pulse, between 96 and 100. Patient also 
takes citrate of iron and quinine. A 8 p.m. patient again complains of severe 
pain. Morphia administered at 9.30 p.m. 

At 3 a.m. on June 14th he was seen by Dr. Ely on account of great pain. 
Morphia was given at that time and one hour later. At 8 o'clock the pain was 
still unrelieved, and the swelling about the angle of the jaw and the mastoid 
process was very much increased. Morphia was freely administered p. r. n., and 
a consultation was held at 1.30 p.m., at which three aural surgeons and one gen- 
eral surgeon were present. The following opinions were given : Dr. , an 

otologist, saw no indication for operative procedure, while he believed there was 
mastoid disease. Dr. , also an otologist, believed that the patient was suffer- 
ing from mastoid disease, and that trephining should be performed at once. 

Dr. , aural surgeon, thought there was no serious internal trouble, that it 

was external, and that the patient was probably suffering from some kind of 
poisoning — malarial ? sewer gas ? that no operation was advisable. The general 
surgeon thought that pus would be found somewhere about the stylo-mastoid 
process, and he thought that nature would relieve the patient by suppuration. 
He laid great stress on the continued application of poultices, and he was not in 
favor of operative interference to-day. Dr. Koosa adhered to his original opinion, 
that the patient had a moderate inflammation of the middle ear, with great neu- 
ralgic pain, and that the swelling of the neck and facial paralysis may have been 
caused by the operative procedures already undertaken, and that trephining was 
not justifiable, but that it would be injurious. It was decided to continue the 
alcohol and to make the application of poultices very thoroughly over the neck 
and mastoid. 

An examination of the urine on June 15th gave the following result : Dark 
straw-color, acid, sp. gr. 1024, albumen in moderate quantity, casts 2, slightly 
granular, uric acid a little, pus a little, mucus a fair amount, oxalate of lime 
a little. 

June 15th. — The ear is suppurating moderately. The drum -head is gran- 
ular, canal moderately swelled, ear easily inflated by Politzer's method. The 
swelling in the course of the sterno-cleido-mastoid muscle, and about the neck, 
seems to be increased, but the tenderness is not so marked. The symptoms 
point to abscess forming in the connective tissue, and in the muscles of the neck, 
and over the mastoid process. Dr. Roosa does not think there is retained pus 
anywhere in the head, or inside of the temporal bone. There is a particularly 
tender point, 1{ in. in a direction directly backward and a little downward from 
the lobe of the ear. There is scarcely any oedema about the Wilde's incision. 
Temperature, 99°; pulse,' 100. 3 p.m.: The swelling has begun to subside. Dr. 

, a general surgeon who had seen the patient on the 13th, saw the patient 

this afternoon, and thinks it possible there is pus in the petrous portion of the 
temporal bone, and that the swelling may be due to a temporary plugging up of 
the communication with the tympanic cavity. 

Dr. Roosa thinks there may be pus in the cellular tissue, but does not think 
that it is necessarily connected with the tympanic cavity. The treatment was 
continued. 

June Kith.— Pulse, 98 ; temperature, W°. Patient slept well. Dr. Koosa 
opened the track of the Wilde's incision with a probe. The swelling and G&dema 
in the mastoid process and about the angle of the jaw remained the same. 



326 NEUROSIS OF MIDDLE EAR. 

Another consultation was held during the day, at which there were present 
two general surgeons, two otologists, and Drs. Roosa and Carpenter. One of 
the surgeons expressed the opinion that the patient's general. condition had im- 
proved since he last saw him, but he declined to express any opinion in regard to 
the necessity for operative interference with the ear. He believed it possible 
that the operations already performed might have aggravated the symptoms. 
The other general surgeon inclined toward trephining the mastoid. This should 
certainly be done in his opinion if there is a probability that there is not a free 
opening from the mastoid cells into the tympanic cavity, and this was a point to 
be decided by the aural surgeons. One of the otologists thought the patient 
better, and that no operation should be done. The other aural expert believed 
that the bone should be opened. Dr. Roosa stated that his opinion was un- 
changed, but that he had so much respect for the opinion of the gentleman who 
was so decided with regard to the necessity for an operation, as well as for that 
of the one who was inclined toward it, that he wished for further advice before 
he declined to open the mastoid. By agreement Dr. Robert F. "Weir, who was 
for some years aural surgeon to the Eye and Ear Infirmary, and who is now sur- 
geon to two general hospitals, was invited to see the patient independently and 
alone, at 9 o'clock this evening, without knowing any of the orjinions that had 
been expressed, until his own was formed. Dr. Weir gave the following opinion : 
that the disease is probably an inflammation extending down the external audi- 
tory canal, in the angle close to the point where the facial nerve passes, and that 
ib may perhaps involve the mastoid process ; he is inclined to think it does not ; 
there is no indication for surgical interference for the present. The general plan 
of treatment was therefore continued. 

June 17th. — An examination of the urine made this day shows specific gravity 
1020, and a well-marked trace of albumen. No casts. The general condition of 
the patient is improving, and the swelling about the neck is subsiding. 

June 19th. — Patient is still doing well. Treatment has been continued. 

The patient made a good recovery, with fair hearing distance, \% at the last 
note, and has been ever since actively employed in his profession. 

I regret very much that the early notes of this case are not 
more full ; yet I think they are sufficiently so to give my readers 
a fair idea of the first symptoms. It is probable, however, that 
the mere recital has not conveyed to the minds of those who 
have followed it a full sense of its doubtful features. They were 
such that, taken in connection with the patient's high profes- 
sional position, they gave me great anxiety lest I should omit to 
do my full surgical duty to the case. The more recent of the 
notes were taken stenographically by Dr. W. M. Carpenter, to 
whom the patient was indebted for intelligent and assiduous 
care. 

The point to be settled during the course of the disease was 
this : Is there a hidden suppurative process going on in any 
part of the temporal bone which causes the pain, oedema, ten- 
derness, cellulitis, myositis, and paralysis of the facial ? My 
answer to the question was, No. The severe paroxysmal pain 



NEUROSIS OF MIDDLE EAR. 327 

did not arouse the suspicion in my mind that there was mastoid 
disease, because there was absolutely no well-defined tender- 
ness, redness, or oedema until leeches and poultices had been 
freely applied, and not until two. paracenteses of the drum-head 
and very free incisions of the auditory canal had been made. 

On May 25th, when I saw the patient after an absence of ten 
days, there was certainly a moderate amount of oedema, and 
this led me, although I suspected it had been caused by the 
leeching, to advocate a Wilde's incision, especially as I then 
thought it a harmless procedure, and two otologists, who had 
seen the patient with Dr. Ely, thought the disease markedly in- 
volved the mastoid, although only one of them advocated any 
operative procedure. I now think that this incision was a mis- 
take, and that to it we owe the increase of the inflammatory 
symptoms in the neck and the facial paralysis. Indeed I now 
believe, on a calm looking over of the case, that every operative 
interference, from my first paracentesis down to the Wilde's in- 
cision, was unnecessary, and that the traumatism needlessly 
aggravated the painful case. The key-note was struck in the 
proper management of the case, in my opinion, when the sup- 
porting, anodyne and anti-malarial treatment, by means of milk, 
alcohol, morphia, and quinine was vigorously entered upon. 

I believe, furthermore, that the disease would have been 
more easily subdued if I had gotten the patient out of his house 
and by the seaside, before the graver symptoms set in. This I 
urged upon the patient and his friends, but without avail. It 
was simply a case of sub-acute, non-suppurative inflammation 
of the Eustachian tube and tympanic cavity, occurring in an 
anaemic, and, consequently, neuralgic and hysterical subject. 
That he was anaemic was not only noted by me at my first inter- 
view, but when Dr. Loomis was called in consultation, he stated 
that he had noticed the doctor's anaemic condition for a year. 

Neuralgic he certainly was, for he had barely gotten through 
with a severe attack of facial neuralgia when the trouble oc- 
curred in the ear. The character of the pain during the whole 
course of the disease was not that arising from deep-seated 
trouble in the middle ear, but rather of a disease like neuralgia, 
in which there is an intensity at different times, and which has 
intervals of complete cessation. It was sometimes easy to divert 
the patient by light conversation or an anecdote, for quite a 
long time, and on some few occasions the use of water in the 
hypodermic syringe was followed by as much effect as the em- 
ployment of morphia. Noav, the character of a pain caused by 
severe inflammatory action in the tympanic cavity or mastoid 
process is such that no physician who has seen much of it would 



328 NEUROSIS OF MIDDLE EAR. 

attempt to alleviate it by any diversion of the patient's spirits 
or by a placebo. Only positive means, such as local blood-let- 
ting or division of the periosteum, will subdue this. I have long 
since recorded my experience ' that morphia alone will not mask 
the severe pain of an acute inflammation of the middle ear. As 
Von Troltsch aptly says, an inflammation of the tympanic cav- 
ity is essentially a periostitis, and every surgeon knows of what 
little avail are drugs against the pain of this disease, except 
when it occurs as a result of the deposition of syphilitic poison. 
It should have been said before that this patient had no syphi- 
litic taint whatever. 

I considered the patient to be nervous and hysterical, because 
he bore his pain very badly, and because he suffered from very 
great depression of spirits. It is not usual, in my experience, 
for a patient suffering from acute inflammation of the middle 
ear, to dwell very much on his prospects of recovery, or to be 
greatly depressed about his future. He is generally taken up so 
much with the severity of his pain as to have room for nothing 
else. Then there was something in the history of the house in 
which the patient lived, which I failed to impress upon some of 
the gentlemen who saw him with me, which led me to believe, 
as was once independently suggested by Dr. Noyes, who saw 
him two or three times, that there was an element of blood- 
poisoning in the case, perhaps from sewer-gas. Two members 
of the family had suffered from acute aural disease a few 
months before, and an examination made by competent au- 
thority late in the course of the case, showed that there was an 
escape of sewer-gas in the cellar. I do not know that any spe- 
cial significance is to be attached to the presence of albumen in 
the urine, but so far as it goes, it indicates a somewhat deteri- 
orated general condition. In analyzing the case, I come over 
and over again to the conviction that the operations did harm. 
That traumatism such as the patient experienced in the para- 
centesis, and in the very free subsequent division of the mem- 
brana tympani, and the free incisions in the auditory canal, and 
the cut down to the mastoid bone, might induce adenitis, myo- 
sitis, cellulitis, and that facial paralysis might result from press- 
ure upon the nerve as it makes its way out of the stylo-mastoid 
foramen, I think does not admit of a doubt. Certainly there 
never was any evidence that the facial suffered any lesion until 
after it had left the cranium and tympanic cavity. Besides, the 
swelling and paralysis occurred at a point of time which makes 
it possible to believe that traumatism may have caused them. 

1 Transactions of the American Otological Society, p. 89. 1875. 



ACUTE SUPPURATION — RESULTS. 329 

But, the crucial test of the correct diagnosis was in the results 
of the case. There was no escape of retained pus either from 
the mastoid or from the neck. It certainly was not pus which 
caused the serious symptoms. When they were at their height 
the discharge from the ear went on, but gradually diminished. 
And when the patient was fairly convalescent, and up and 
about, the old swelling and redness of the neck reappeared for 
several hours. Besides, it should be noted that no chill occurred 
during the progress of the case. This fact, together with the 
clearness of the patient's intellect, gave me great encourage- 
ment, when I was struggling against the opinion of a valued 
colleague, who thought the patient was dying for want of an 

operation. Dr. S was relieved after large doses of quinine 

at a time when the pain was intense, and when these seemed to 
fail, he was permanently cured after the full doses of alcohol 
advised by Dr. Loomis. 

From the nature of things, the general practitioner will see 
a great deal of acute disease of the middle ear — if he be on the 
lookout for it — since it occurs so often in the course of the ex- 
anthemata and in connection with diseases of the respiratory 
organs. It will be seen that there is nothing in the treatment 
of this affection that will prevent the usual care of the general 
disease. It is a great and often fatal error to wait the subsid- 
ence of the general symptoms before the aural ones are allevi- 
ated. They are quite as important as the most urgent consti- 
tutional disturbances. Indeed, they are often the unsuspected 
cause of most of the latter. 

It only remains to be said that the results of treatment of 
this disease are very satisfactory. I think more than seventy- 
five per cent, of these cases are cured, that is, the membrana 
tympani is restored and the hearing power becomes normal. As 
has been said in another place, the old writers on diseases of the 
ear were not in the habit of applying accurate tests as to the 
restoration of hearing ; so that their standard of cure is not so 
high as that which obtains among writers of the present day. 
Many of my cases of aural disease, that have been reported as 
improved or much improved, would have been classed under the 
head of cured, by the less exact standard of ancient writers. 
Where one ear only is affected, we are apt to he led into error 
as to the amount of deafness, unless we are careful to exclude 
the sound ear as thoroughly as may be in our examination. 

The consequences of a neglected or improperly treated aural 
catarrh are, that it runs into a case o( acute suppuration ; hut 
those of a neglected or maltreated acute suppuration are still 
more grave, involving as they do all the perils of long-continued 



330 ACUTE SUPPUKATIOX — RESULTS. 

suppuration in the ear. And yet, to this day, there are medical 
men of very great general intelligence, who think lightly of such 
a disease, and gravely advise patients not to "meddle" with it. 
The author has been informed by a distinguished practitioner in 
this city, that a young man was once sent to him for advice by 
an eminent physician, after he had passed through a severe con- 
stitutional disease in which suppuration in the middle ears had 
occurred, for whose ears not one particle of rational advice had 
been given, although both membrana3 tympani had been de- 
stroyed, the ossicula were gone, and the mucous membrane of the 
tympanic cavity was granular. Such neglect needs no com- 
mentary. 

Occasionally I receive a note from a general practitioner, 
which conveys the impression to me, that it is supposed by some, 
that peculiar means of treatment are at the service of specialists 
which are not in the hands of the average physician, and which 
can only be used when a disease has become well advanced. To 
those who hold such views, I would say, the time to treat aural 
disease is in the beginning of the attack. Aurists or surgeons 
have no means to combat inflammation other than those at 
the hands of every practitioner. To wait for so-called special 
treatment is to lose important time. Besides this, there is no 
special, mysterious treatment that can be of avail at any time, 
no matter in what hands. It is true that we must wait for a cat- 
aract to ripen, before it can be removed, and then only an expert 
is competent to operate upon it. But no such condition of things 
exists in the progress of aural disease. Delay in its manage- 
ment will be as fatal to a cure, as is delay in the treatment of 
glaucoma. 

The course of acute suppuration occurring in the midst of 
a severe attack of scarlatina, is apt to be violent. The symp- 
toms follow one another with the rapidity of those of purulent 
ophthalmia. He who wishes to preserve the integrity of the 
organ, must be prompt and energetic in his treatment, or the 
drum-head and the ossicula auclitus will be swept away, and a 
profuse and fetid discharge of pus be set up within forty-eight 
or fifty-six hours. 

It should also be said as supplementary to this subject, that 
attacks of acute aural catarrh, or of acute suppuration of the 
middle ear, are more dangerous in persons who are affected with 
a chronic catarrh of the middle ear. This is explained by the 
fact, that the drum membrane is so much thickened in such cases 
that the exit of the pus or mucus by its spontaneous perforation 
is much more difficult. A paracentesis will be much more likely 
to be required for them, than in those occurring in persons with 



ACUTE SUPPURATION — CASES. 331 

drum membranes of normal density and tension. I may also 
remark, that I have seen erysipelas of the face of a severe type, 
occur in the course of acute suppuration of the middle ear. This 
is, of course, a serious complication, but as yet I have seen no 
fatal results from it. More will be said of this, in the chapter 
upon "Diseases of the Mastoid." 

The following cases may be said to be fairly typical, and to 
show the ordinary course of the different forms of acute sup- 
puration of the middle ear. 

Case I. — Acute Suppuration from Scarlet Fever — Loss of the Malleus of each 
Side — Reproduction of the Membrana Tympani — Great Improvement in Hearing 

Power. — Harry , aged nine. On February 27, 1872, I was called by Dr. G. 

S. Winston, to see the grandchild of a gentleman of this city, in regard to whose 
case I had already given advice by mail and telegraph. The history was as fol- 
lows : The boy had gone back to his school, after spending the Christmas holi- 
days at home, in quite as good health as usual ; but soon after arriving he was 
attacked with scarlet fever, which rapidly assumed a very severe type, so that 
his throat was inflamed and the cervical glands were swelled, and the lining 
membrane of the middle ears was in a state of very acute inflammation. In 
spite of prompt and energetic treatment by the physician of the school, sup- 
puration occurred in a few hours. After the aural symptoms occurred, the dis- 
charge of pus became profuse, so that the ears needed cleansing every half 
hour. The malleus bone of each ear escaped in the pus, and I have them in 
my possession. When the severest aural symptoms had subsided, astringents 
were used in the auditory canal, and the Eustachian tubes treated by Politzer's 
method. 

As soon as the little patient's general condition would allow, he was returned 
to his home, and in a deplorable condition. His ears were discharging thick, 
offensive pus, in such quantities, that it was only by the greatest diligence in 
cleansing that they could be kept clean ; the naso-pharyngeal space was secret- 
ing muco-purulent material in great masses. The hearing power was so much 
impaired that it was only by speaking in a distinct and loud tone, close to the 
little fellow's ear, that he could be made to understand what was said to him. 

The family and friends believed that he would become the inmate of a deaf 
and dumb asylum. Indeed, a gentleman — a friend of the family — who had a 
child that, having lost her hearing from the scarlet fever, had learned the 
method of speech by watching the lips, came to see Harry, and urged that very 
prompt measures should be taken to cause him to learn lip reading, inasmuch 
as he felt certain that he would never hear sufficiently to retain his speech, I 
at once instructed the family to converse regularly with the little patient, to 
read aloud to him, and to urge him to continue to talk, while the local and 
general treatment were carried on. This they did with a remarkable faithful- 
ness, so that the boy, hearing what was said to him, never acquired an un- 
natural tone of voice. 

On examination it was found that the membrana tympani of each side was 
gone, and that the cavity of the tympanum was tilled up with granular mucous 
membrane. The hearing distance for the watch was ft on each side. The 
voice of a person speaking with great distinctness was heard two feet from the 



332 ACUTE SUPPURATION— CASES. 

left ear, and one from the right. Air could be forced through both Eustachian 
tubes. The patient's general condition was fair ; but he was suffering from 
some abdominal effusion. Dr. T. F. Cock was called in on this account, and 
ordered the tincture of the sesquichloride of iron. The weather being cold, the 
boy was kept in the house, and in a warm room ; while a thorough local treat- 
ment was entered upon. The ears were syringed by some member of the family 
every hour during the day, if necessary ; while I visited him at first twice, and 
subsequently once a day, and cleansed the ears with the syringe and cotton- 
holder, inflated the ears by Politzer's method, and applied a solution of nitrate of 
silver, of the strength of forty grains to the ounce, to the cavity of the tympanum. 
The family applied a weak solution of sulphate of zinc in the evening. The 
naso-pharyngeal space was cleansed by the use of chlorate of potash. A weak 
solution of Labarraque's solution of chlorinated soda was used in the water 
employed for syringing the ear, in order to diminish the fetid odor of the pus. 
Under this treatment the patient steadily improved until the discharge of pus 
had entirely ceased from the left ear, and a membrana tympani had formed at 
the bottom of the canal, with a small central aperture, and in the right there 
was also a membrane, with a larger opening, and a very slight muco-purulent 
discharge. On May 11th, about three months and a half from his return to the 
city, and about five months from the breaking out of the scarlet fever, he could 
hear the voice, with his face away from the speaker, for a distance of twenty 
feet, and the watch, E. E., -/»- ; L., -/«. He returned to school in good general 
health. 

January 9, 1873. — He still continues at school, with hearing power the same 
as last noted. The membrana tympani of left ear is entirely closed. In the 
right there is still a small opening, and occasionally a discharge of pus. The 
ear is carefully cleansed at school, an astringent is still used, and Politzer's 
method of inflation is occasionally practised. 

The above case illustrates what can be done for one of the 
severest cases of acute suppuration in the middle ear, resulting 
from the pharyngeal inflammation of scarlet fever. Hundreds 
of such subjects have become inmates of deaf and dumb asylums, 
and are consequently educated in a necessarily imperfect man- 
ner. This boy, although under some obstacles, has been educated 
exactly as are his fellows, who enjoy good hearing power. He 
is now engaged in active business pursuits. 

Case II. — Acute Suppuration of the Middle Ear, occurring in a Child, in Con- 
nection with the Whooping-cough — Membranes Healed in about a Month. — March 

12, 1872. — Eugene , aged one, a rather delicate child, who is passing 

through the whooping-cough. A few days ago the child cried very much for 
some hours, and then a discharge of pus, mingled with blood, was found from 
each auditory canal. The spasms of coughing are very severe. I was called to 
see the little patient a few days after the discharge of pus occurred, and I found 
on examination that both membranse tympani were ruptured, and that consider- 
able pus was being secreted in the cavity of the tympanum. There was also 
some naso-pharyngeal catarrh. 

The following treatment was entered upon: The ears were syringed three 



ACUTE SUPPUEATION— CASES. 333 

times a day, with lukewarm water, and a solution of sulphate of zinc, gr. ij. 
ad § j., was afterward dropped into the meatus, and kept there for a few minutes. 
I saw the patient three times a week, and cleansed the ear myself. On April 
15th, or a little more than a month from the time the perforation occurred, both 
drum-heads had healed and the discharge had ceased. 

Case III. — Acute Suppuration in the Course of Chronic Nasal Catarrh — Para- 
centesis of the Membrana Tympani. — March 13, 1873. — George S , aged thirty- 
four. He has had "catarrh" for two years, for which he has been in the habi: 
of using injections through the nostrils by means of Davidson's syringe, For 
the past few hours he has had a rjain in the ears, but more particularly in the 
left, and he cannot hear well. 

An examination shows that the patient has a severe form of naso-pharyngeal 
inflammation, attended by a profuse and fetid secretion. The hearing distance 
is, E. E., ts; L. E., 4%. The right membrana tympani is sunken and red. The 
left membrane is very convex ; a delicate pink tint involves the whole surface, 
and there is no trace of the handle of the malleus nor of the light spot. 

The membrane was immediately incised in the upper and posterior quadrant, 
and a small amount of pus was evacuated. The ears were inflated by Politzer's 
method, and the auditory canals syringed with tepid water. A leech was applied 
upon the tragus of the right ear. A profuse suppuration occurred in the left 
ear ; but it was soon checked by the use of a solution, gr. xl. ad § j., of nitrate of 
silver painted over the drum-head, and the patient disappeared from observation, 
with the hearing distance £f on each side, on March 22 d, or nine days from 
the date of the first visit. I afterward learned that he considered himself 
entirely well. 

Case IV. — Inflammation of Auditory Canal extending to the Membrana Tym- 
pani — Paracentesis — Cure. — Mrs. G , aged about thirty-five. On April 16, 

1872, I was sent for, by request of Professor T. G. Thomas, to see this patient, 
who had been suffering for a week or two from occasional attacks of severe pain 
referred to the depth of the right ear. These attacks had been alleviated by the 
application of leeches, but the pain continued to recur, especially at night, so 
that the patient was unable to sleep. I found the lady suffering very much, 
and she had been awake with pain all night. The auditory canal was found to 
be swelled, and there were two points of suppuration in the cartilaginous part 
of the meatus. The membrana tympani was red, but its whole surface could not 
be seen on account of the swelling of the canal. The auditory canal was scari- 
fied at two points, and the use of the douche ordered every hour ; fg gr. of sul- 
phate morphia was ordered to be taken every hour, until the pain was relieved. 
In the evening the pain not being markedly relieved, two leeches wore ordered 
to be applied to the ear — one on the tragus, the other at the glenoid fossa. 
This, with the continuation of the morphia, quieted the pain very much ; but. 

on the 19th, I was called early in the morning, to find that Mrs. G had had 

a recurrence of the pain, and that she was suffering very much. I then made a 
paracentesis of the drum membrane, although the swelling of the canal was so 
great that I could only judge of the fact of my instrument a cataract needle — 
having passed through the membrane, by the depth to which it penetrated, and 
the yielding sensation communicated to the fingers as the needle passed through 
the drum-head. Immediate and great relief from the pain was experienced, and 



S34 ACUTE SUPPURATIOX— CASES. 

the patient, under the continuation of the douche, daily syringing, the use of 
Politzer's method of inflation, on May 11th she had fully recovered her hearing 
power with a moderate amount of suppuration. 

I am not able to decide whether this case was primarily one 
of otitis externa, or otitis media. I am inclined to think that it 
was one of the former, and that the inflammatory process ex- 
tended to the membrana tympani from without. I suppose that 
the membrane was unusually thick, perhaps from a previous 
morbid process, and that this accounts for its continuing intact 
for a longer time than usual, although a membrana tympani 
that is invaded by disease from the auditory canal, will with- 
stand an inflammatory action without rupture much longer, 
than one whose mucous layer is the first affected. 

Case V. — Acute Suppurative Otitis Media of some days' standing, Cured by one 
Application of a Forty grain Solution of Nitrate of Silver. — February 16, 1873. — 

G. C , aged one year. I was asked to see this little patient by Dr. C. C. Lee. 

There had been an acute naso-pharyngeal catarrh for some time, and for a few 
days there had been a purulent discharge from the left ear. On examination 
the drum membrane was found to be perforate, and there was a profuse discharge 
of pus. The ear was kept carefully cleansed, and a warmed solution of sulphate 
of zinc poured into it ; but it did not yield in a day or two, when a solution of 
nitrate of silver, of forty grains to the ounce, was brushed over the canal and 
the perforated membrana tympani. At my next visit, the morning after this 
application was made, the discharge had completely ceased, and the membrana 
tympani had healed. 

The foregoing cases, illustrate the ordinary type of acute sup- 
puration occurring in subjects of different ages. The practi- 
tioner who has not seen much of aural disease, may be at a loss 
when called to a case of acute suppuration of the ear, to know 
whether its seat is in the auditory canal or the middle ear. The 
parts should be carefully cleansed of pus before a decision is 
made, although it should be borne in mind, as was stated in the 
chapter on "Acute Affections of the Canal," that suppuration in 
the middle ear is much more frequent than the same process in 
the external auditory canal. Indeed, an acute diffuse suppura- 
tion of the external ear is an extremely rare disease. If an open- 
ing in the drum-head cannot be detected by the otoscope, the 
performance of the Valsalvian experiment by the patient, or the 
employment of Politzer's method, and a subsequent inspection, 
will determine the question. If the membrane be perforate, the 
air will be heard to whistle through the aperture, and an air- 
bubble, made by the pus or mucus, will be found at the seat of 
the aperture. The presence of an air-bubble, before the parts 
have been cleansed, is not, as Wilde thought, a pathognomonic 



SEROUS INFLAMMATION. 335 

symptom of a perforation, for I have seen this bubble when the 
membrane was intact, but fluid was lying upon it. 



SEROUS INFLAMMATION OF THE MIDDLE EAR. 

An increased secretion of the middle ear, is not always either 
of a catarrhal or a purulent character. As has been observed in 
the account of the anatomy of this part, its lining membrane 
sometimes assumes the character of a serous membrane. In 
like manner an excessive secretion in the middle ear may be, in 
exceptional cases, predominantly or entirely of a serous char- 
acter. This may occur when the membrana tympani is sound, 
and also during the course of a suppurative process. The mem- 
brana tympani, if entire, has an unmistakable appearance, when 
serum is collected behind it in great quantity. It is somewhat 
bulging, and through its transparent layers may be detected a 
yellowish fluid, which may be caused to change its position by 
movements of the head, just as hypopyon may be made to 
change its position in the anterior chamber of the eye. The 
subjective symptoms of this accumulation, like those from the 
accumulations of mucus, are sometimes very annoying and 
trying, without being absolutely painful. The movement of 
the serum is felt by the patient at each considerable change 
in position, especially on rising from lying down, and some- 
times the sound of his voice becomes very distressing, and even 
"echo" hearing and double hearing may be present, just as it 
may be when mucus has accumulated in the ear in sub-acute 
catarrh. The hearing power is very much affected in these 
cases, but it may be variable, according as the serous fluid has 
changed its position. Great pain is sometimes spoken of by 
patients, but this is usually in neurotic or hysterical subjects, 
for, from all I can learn, while the presence of serum in the 
middle ear causes very annoying and disturbing sensations. 
they are not to be compared in severity with those from the 
accumulation of mucus, blood, or pus. Dr. Tansley 1 reported a 
case of serous inflammation of the middle ear. occurring in a 
woman of advanced age, and because his case was not marked 
by severe pain, he proposes to divide these cases into two classes. 
inflammatory and non-inflammatory. To the latter he gives the 
name of hydro-tympanum. This, 1 think, is a needless and un- 
necessary refinement in nomenclature, which may possibly lead 
to a confusion of ideas. Some cases oi' serous inflammation of 
the middle ear are attended by pain, and others are not, just as 



1 Archives of Clinical Surgery, July 25, 1878. 



336 SEROUS INFLAMMATION. 

we may have a painless suppuration of the middle ear. But as 
I have already observed, annoying as is a serous inflammation 
of the tympanum, it is not usually painful in the same sense 
that acute catarrh or suppuration are found to be. As has been 
already said, an accumulation of serous fluid in the tympanum 
may occur in the course of a suppurative process, and it may bo 
added, that it is very difficult to manage from the rapid reac- 
cumulation of the serum. Serous accumulations are apt to oc- 
cur, in my experience, in debilitated subjects. The inflamma- 
tion may be considered, I think, as of a bastard type. 

Dr. C. H. Burnett * reports a case of repeated accumulations 
of serous-like fluid, in the t3 r mpanum of a man fifty-five years 
of age. The membrana tympani was opened thirty-seven times 
by Dr. Burnett in nine years, and always with relief to the pa- 
tient. In an obstinate case of this kind, I once made as many as 
five openings in the drum-head in a few weeks. The patient 
was a very nervous woman of some fifty years of age, and al- 
though she got relief at every operation, it was temporary, and 
she sought other advice. Burnett entitles his case dropsy of the 
middle ear. 

Treatment. — Paracentesis of the drum-head is often indicated 
in cases of serous accumulation, although at times the fluid may 
disappear under the treatment of the middle ear by inflation. 
At the same time, the general health will need careful looking 
after. Generally, paracentesis must be repeatedly performed in 
the same case before a cure results. Siegle's otoscope with Ely's 
attachment, will be found very useful in drawing the serous - 
like fluid, or serum, or tenacious mucus from the tympanum. 
Of the accumulation of serum and mucus in chronic cases, more 
will be said in an appropriate chapter. Leeches and the warm 
douche are of little or no avail in serous inflammation, but the 
use of gargles is strongly indicated. By them, the action of the 
Eustachian tube and the consequent passage of the fluid from 
the tympanum to the pharynx, are promoted. 

1 American Journal of the Medical Sciences, January, 1884, p. 122. 



CHAPTER XIIL 

CHKONIC NON-SUPPUEATIVE INFLAMMATION OF THE MID- 
DLE EAE. 

Frequency of this Disease. — Nomenclature. — Catarrh. — Proliferous Inflammation.-- 
Subjective Symptoms. — Vertigo. — Tinnitus Aurium. — Insanity. — Subjective 
Symptoms of Proliferous Inflammation — Objective Symptoms. — Impairment of 
Hearing. — Changes in the Membrana Tympani. — Eustachian Tube. — Nasophar- 
yngeal Inflammation. — Adenoid Growths. —Pathology. — Causes. 

It has been a common reproach both from the profession and 
the laity, that the treatment of aural disease is unsuccessful. In 
1870 one of the Boylston prize questions was as follows : " Crit- 
icisms on the recent opinion of a medical writer that the less 
serious diseases of the ear may be successfully treated by a well- 
qualified general practitioner, and the more serious affections 
by none." When Von Troltsch, announced his intention to de- 
vote himself to the study and treatment of aural disease, one of 
his professional friends warned him that he might put his good 
name in jeopardy. These incorrect ideas have arisen chiefly 
from ignorance as to the nature and causes of diseases of the 
ear. There is a large class of cases in this department of medi- 
cine, that at the very best can only be alleviated, and can never 
be cured. But many of these, have reached such a classification 
from a point where treatment would have been of the greatest 
avail. The prevention of a chronic aural affection is often with- 
in the power of every practitioner, while it once having become 
established, its cure is impossible. After many years of careful 
study of diseases of the ear, I think it may be said that there 
are but two classes of cases of aural disease in which we may 
not expect very good results from treatment and care. Nearly 
all the others are singularly tractable, when their course is 
properly regulated. 

By these two classes I mean chronic non-suppurative inflam- 
mation of the middle ear. and the affections oi' the labyrinth, 
or internal ear. 

Of every thousand cases oi* aural disease about three huu- 
22 



338 CHROMIC NON-SUPPUKATIVE INFLAMMATION". 

dred belong to the former class, while but a small percentage of 
disease of the internal ear occurs. 

Chronic non-suppurative inflammation of the middle ear, is 
so insidious in its origin and progress, that it may have existed 
for months and years before its subject is aware of it, and brings 
himself under professional care. It may impair or nearly de- 
stroy the hearing, with but few of the subjective evidences of- 
what is called inflammation — there may be no heat, redness, or 
pain — but we find many of the other marks of diseased action, 
in swelling, thickening, adhesions, which entitle it to be placed 
under this head. It has also been called a catarrhal inflamma- 
tion, because the cavity, air-chamber, and tube, which form its 
seat, are lined by mucous membrane. We say middle ear, be- 
cause these parts form the anatomical centre of the organ of 
hearing. It is the same disease which Sir William Wilde under- 
stood, but which, as it seems to me, he inappropriately called 
chronic myringitis, or inflammation of the drum-head. But the 
drum-head is only one of other parts that is affected in this dis- 
ease, and may, perhaps, be scarcely at all injured, while the 
most important changes in structure and function have occurred 
in other parts of the middle ear. In common speech — and I do 
not mean by this, among the laity, but in the profession — many 
of the forms of chronic non- suppurative inflammations of the 
middle ear, have been, from time immemorial, classified as ner- 
vous. The great author whom I have just quoted, did much to 
combat this error — an error which not only kept back the growth 
of the science of otology, because it retarded the conception of a 
successful plan of treatment, but which also assisted to deepen 
the reproach which for centuries has rendered aural disease 
the bete noir of medical practice. 

The reason for this classification of these affections as ner- 
vous is found in the fact that the poor means of diagnosis, 
which were in the hands of the profession until a few years 
since, the absence of a simple otoscope, and the want of 
knowledge of the value of the Eustachian catheter, and the 
tuning-fork, did not allow of the appreciation of the delicate 
changes which make up what the Germans call the " Krank- 
heitsbild " — the picture of the disease. There was another rea- 
son in the fact that the poor, distressed patient, having gone in 
vain to his usual consolers, if not curers— the regular practi- 
tioners — often resorted to the charlatan. Under his wonderful 
but distressing treatment, added to the trial of the horrible tin- 
nitus aurium, and impairment of hearing, he became so utterly 
worn out and so distrustful of each new adviser, that the so- 
called nervousness was very apparent. 



NONSUPPURATIVE INFLAMMATION. 339 

The common idea of nervous deafness is that it occurs chiefly 
among the weak and sensitive ; but this notion has no basis in 
pathology — so-called nervous people are not apt to be deaf, nor 
does their sensitive or nervous organism have much effect upon 
their hearing power, unless it is already impaired from an in- 
flammatory cause. 

As yet, this class of cases comes as a rule to the notice of the 
practitioner of modern otology, only when the disease is far ad- 
vanced. 

The following table shows this. It is compiled from the first 
cases of this disease that were observed by me in private practice: 

Cases of Chronic Nonsuppurative Inflammation. 

Number of cases of 80 years' standing 1 

* ' over 40 years' standing 6 

over 20 " " 40 

" between 10 and 20 years' standing 133 

5 and 10 " " 141 

3 and 5 " " 75 

land 3 <( " 74 

' ' one year's standing , 42 

" less than one year's standing 13 

Total 525 

It will be seen that by far the larger number, more than fifty 
per centum, had observed some loss of function for more than 
iive years, while about eight per cent, had been affected for more 
than twenty years. 

I add a second table made from the last five hundred and ten 
cases : 

Oases of 50 years' duration 1 

40 " " 5 

30 to 40 years' duration 6 

20 to 30 " " 30 

15 to 20 ' " " 27 

10 to 15 " " 77 

5 to 10 " " 112 

4 years' duration 43 

3 " " 53 

2 " " 76 

1 year's " 41 

6 months' " 18 

3 " " 21 

Total 510 

It will be seen that even in the second table the proportion of 
cases of from ^ve to twenty years' standing is very largo, nearly 



340 chronic xox-supprRATivE ixfl A:\nr atiox. 

one half of the whole number, but there is a gratifying increase 
in the number of those that have existed less than one year. 

Every person has. so to speak, a superfluous amount of hear- 
ing, which he may lose before his hearing is sufficiently impaired 
to annoy him in the common affairs of life. People who spend 
many hours of the day in noisy places, such as boiler-shops, on 
board steamships, in the stock-board of \Vall Street, as I have 
seen by frequent examples, may lose very much of their hearing 
power before they are at all aware of it. Then, again, the lower 
classes, who labor hard all day in the open air with their fellows, 
and who live at night in small and noisy rooms, where the 
demands upon the hearing power are very slight, hardly con- 
sider its impairment as a loss of function. 

Besides all this, people in general, who have no scruples about 
confessing to impaired eyesight, very reluctantly admit a loss 
of hearing. It thus becomes very difficult in many cases to say 
when an impairment of hearing was first observed. 

These causes have conspired, with the general ignorance of 
the pathology and treatment of non -suppurative aural disease, 
to render the results of treatment unsatisfactory, as well as to 
cause patients to consult a physician at a very late stage of their 
trouble. 

I have never been fully satisfied with the nomenclature of 
Yon Troltsch, vast improvement as it Avas on those classifica- 
tions which had preceded it. Some of them were crude, others 
fanciful and altogether too refined. Yon Troltsch, classified all 
non-suppurative disease as catarrhal, and then separated those 
in which the catarrhal symptom — excess of secretion — was not 
very marked, by placing them under the head of sclerosis or 
hardening or rigidity of the mucous membrane. After looking 
at many ears, in which there was no trace, either in the pharynx. 
Eustachian tube, or cavity of the tympanum, of an excess of 
secretion from the mucous membrane, but in which there were 
marked changes in the way of increase, hypertrophy or prolifera- 
tion of tissue, and in others where the catarrhal symptoms were 
very much in the background, although they existed, I felt that 
aural catarrh was a meagre and incorrect name with which to 
describe such a state of things. The very name "catarrh," as 
applied to an ear with a sunken drum-head, immovable chain of 
bones, dry pharynx, easily permeable Eustachian tubes, is repug- 
nant to all our notions of scientific nomenclature. Whatever 
may have been the origin or exciting cause of such cases, they 
cannot be called catarrhal, when their examination shows such 
a state of things as this. 

Gruber has made a division in his text-book, and describes 



CATARRHAL AND PROLIFEROUS FORMS. 341 

an otitis media hypertrophica, or plastic inflammation ; but I 
think his own description of the pathology of the disease shows 
that he is discussing not what has hitherto been comprehended 
under the head of sclerosis, but an extension of a suppurative 
process, such as causes the formation of granulations or polypi. 
This criticism has also been made by Politzer. 

My classification is founded upon clinical experience, and 
upon the reports of the pathology of this class of cases that have 
been made by Toynbee, and others. 

Chronic non-suppurative inflammations of the middle ear 
may be divided into two great classes, 

Catarrhal, 
Proliferous. 

I choose the translation of the German word tvucherung, as 
furnishing the best term to describe the changes in the middle 
ear, of which I am to speak ; and in what I have to say, I shall 
attempt to be guided by these divisions. 

Since the publication of the first edition of this work, the term 
chronic non-suppurative inflammation, has been widely adopted 
in Great Britain as well as in this country, and some authorities 
have also accepted the term proliferous, in the sub-classification. 

Some authors and practitioners would admit another classifi- 
cation, based upon the parts involved, and speak of chronic 
myringitis, or chronic inflammation of the membrana tympani, 
of the tympanum, and of chronic catarrh of the Eustachian tube. 
Whatever we may believe of acute inflammation of these parts, 
I can scarcely accept the idea of one that has existed for any 
considerable space of time without involving either the cavity of 
the tympanum or the mastoid cells, or both. The nomenclature, 
tubal catarrh, also leads, as I believe, to incorrect notions as 
to the therapeutic value of the Eustachian catheter, and of Po- 
litzer's method of inflating the drum cavity. These methods of 
treatment are useful, not so much for what they do to the tube, 
as for their effect upon the cavities into which it opens. When 
air-bubbles are crackling in the cavity of the tympanum, as in 
catarrhal inflammation, or when the tube is greatly narrowed 
by the hypertrophy of its lining membranes, but at the same 
time we have, as we always do. in the latter case, a sunken 
drum-head, an altered light spot, signs of proliferous inflamma- 
tion of many of the structures making up the middle ear. 1 do 
not see how we can with propriety speak of a tubal affection, 
even if its symptoms are predominant, and even if treatment of. 
and through, the lining membrane of the tube, does place things 
in such a condition that Nature will complete the cure. No time 
need be spent upon this question, which may, perhaps, seem to 



342 CHRONIC CATARRHAL INFLAMMATION. 

some a comparatively unimportant one, bad not incorrect notions 
in the past led to an incorrect style of treatment. In former 
times, the membrana tympani, under the assumption that such 
an affection as an independent chronic myringitis existed, was 
vigorously treated by instillations of various fluids, and by per- 
foration, and of late, under the idea that we have a great deal 
of tubal catarrh without further progress in the morbid action, 
undue stress is sometimes laid upon applications to the mouth of 
the tube. Politzer's method is then used as a complete substitute 
for the catheter, when in my opinion, indispensable as it is, its 
chief value is as an adjuvant to that instrument. 

SUBJECTIVE SYMPTOMS OF CHRONIC CATARRHAL INFLAMMATION. 

I think we may assume, from the history of cases, that this 
form of disease is either a consequent of frequent attacks of 
acute catarrh of the middle ear, or that it occurs in people who 
have what we may call a catarrhal diathesis. Those who suffer 
from hay fever, are very apt in time to be affected with chronic 
catarrh of the middle ears. The disease is, therefore, unlike its 
companion, proliferous inflammation, not at all insidious in its 
approach. The patient suffering from this disease, who con- 
sults us about his hearing, is usually aware that there is an ex- 
cess of secretion in his pharynx, and that for years he has been 
annoyed and troubled by being obliged to use a handkerchief 
very freely, and by feelings of fulness referred to the frontal 
sinus and tympanic cavities. There is often, also, at times, a 
sound in the ear like the crackling of air-bubbles. The voices 
of friends appear muffled ; and it is hard for the victims of 
chronic aural catarrh, when the disease is advancing, not to be- 
lieve that every one is speaking in a much lower tone than is 
usual for them. Such patients often complain bitterly on this 
subject, and will scarcely admit that their hearing is at all im- 
paired, or, if so, they stoutly assert that it is one ear only, when 
the fact is, that, with one perfect ear, it is only under peculiar 
circumstances, certainly not in ordinary conversation, in front 
of the patient, that a person will be observed to be at all hard of 
hearing. 

There is a feeling about this that is different from that ex- 
pressed about diseases of the eye at least, and I believe, in most 
maladies, patients will express their feelings, and often with an 
exaggeration, rather than with an extenuation of the symp- 
toms ; but, however much patients with chronic inflammation 
of the middle ear may suffer from impairment of hearing, they 
will often insist that they are hardly affected, or that they have 



VEETIGO IN DISEASE OF THE MIDDLE EAPw. 343 

a very little trouble in that way, when they can scarcely hear 
loud conversation addressed specially to them. 

Patients affected with chronic catarrh of the middle ear also 
complain, as a rule, of tinnitus aurium, and a sense of fulness 
in the ears. The ears feel as if the auditory canals were stopped 
up. They often ask very anxiously, if there is not something in 
the ear, and seem incredulous when the negative answer is 
given. Vertigo is another symptom of which these patients 
sometimes speak, and it is often considered as undoubted evi- 
dence that there is disease of the brain. Vertigo is a symptom 
by no means peculiar to catarrhal inflammation. It also occurs 
in impacted cerumen, and still more frequently in proliferous 
inflammation, as well as in affections of the labyrinth and in 
cerebral disease. When vertigo occurs in aural disease, it is a 
consequence of increased pressure upon the labyrinth through 
the fenestra ovalis or of an affection of the labyrinth or brain. 
It is by no means a serious symptom, when the cause is to be 
found in the middle ear, for it is usually relieved by a mechan- 
ical treatment through the Eustachian catheter. There are 
many cases in my note-book which illustrate this, but none 
more striking than the following : 

A physician once consulted me on account of impairment of 
hearing in one ear, accompanied by a tendency to topple over 
on that side, which he said was a consequence of being thrown 
from his sleigh some months before, when he suffered a concus- 
sion of the brain. He was quite disposed to regard the tendency 
to fall over, as a cerebral lesion, but the use of the Eustachian 
catheter and Politzer's method of inflating the ear not only im- 
proved the hearing, but took away the unpleasant sensation. 
Physician as he was, he was at first disposed to smile at the 
idea of using local means to ameliorate this brain-symptom ; 
but he has continued to be perfectly relieved from his cere- 
bral malady up to this time, ten years or more since he con- 
sulted me. 

The subject of aural vertigo has been very much confused 
by the disposition, especially found among neurologists, to at- 
tach the name of "Meniere's disease" to every case of aural 
disease in which vertigo is a symptom. This will be more fully 
discussed in a subsequent chapter, but it may be well to say 
here that vertigo occurs at times in such a large variety of aural 
cases, that it would be well to abolish the name of Meniere's 
disease, except with reference to those eases where the origin 
of the vertigo is undoubtedly in the labyrinth, ami where it is 
not plainly secondary to an affection of the auditory canal or 
middle ear. As now used it describes nothing, and leads to 



344 INSANITY FROM AURAL DISEASE. 

want of exactness in the diagnosis. I have just dismissed from 
my care a young woman, who became very ill from acute catarrh 
of the middle ears, accompanied by vertigo, the tendency being 
to pitch forward. By the use of leeches, blisters, and inflation 
of the middle ears the symptom of vertigo was relieved in 
twenty-four hours, and disappeared wholly in two days. The 
leeching and the inflation both afforded immediate relief. 

I have often heard patients describe the feeling of fulness in 
the ears as a sensation as if the ears were plugged with some 
foreign substance ; it is almost impossible for them to avoid the 
impression that the auditory canals are plugged with cerumen. 
Very many times, after I have examined a patient suffering 
from chronic disease of the middle ear, I have been asked to 
look again to see whether I could not find some hardened wax ; 
and on one occasion a poor fellow who I suppose was, to a cer- 
tain extent, insane, grew very angry and called me hard names, 
because 1 would not remove wax which he knew was in his ear. 

Troltsch * relates a case from Meyer, of Hamburg, where a 
melancholic person was relieved of a sound in the ear, seeming 
to him to be the cry of a child, by the removal of a plug of ceru- 
men, which caused deafness on one side. The patient made a 
rapid and complete recovery from the mental affection, after 
the cerumen was removed. It is the opinion of Schwartze/ 
that subjective aural sensations, which are caused by demon- 
strable affections of the ear, may, in predisposed persons, es- 
pecially when there is any hereditary tendency to mental dis- 
ease, become the direct cause of aural hallucinations, that may 
accelerate the outbreak of a disease of the brain. He mentions 
a case where, in his opinion, and in that of one of the physicians 
of the Insane Asylum at Halle, a threatened attack of brain dis- 
ease was prevented by treatment of the ear. In some cases, 
insane persons, who suffer from aural disease, distinguish its 
tinnitus from these illusions or hallucinations. 

Dr. Koppe confirms this view, and shows that in some cases 
hallucinations disappear after treatment of the ear. 

1 have elsewhere reported 3 a case of the suicide of a pro- 
fessor in one of our educational institutions, who consulted me 
on account of impairment of hearing, but more especially on 
account of tinnitus aurium. He said, on leaving- the consulting- 
room, that, if he felt sure that I was correct in my opinion (that 
he would not get great relief from this very trying symptom, 
tinnitus), he would put an end to his existence ; which he did a 

1 Text-book, second American edition, p. 531. 

2 Loc. cit., p. 532. 3 New York Medical Journal, August, 1869. 



INSANITY FROM AURAL DISEASE. 345 

few months after, by blowing out his brains. A few years since 
a gentleman, a public-school teacher, consulted Dr. Charles 8. 
Bull, while he was in charge of my patients, in regard to a sup- 
puration of the ear, which caused considerable impairment of 
hearing and great tinnitus. He was exceedingly depressed and 
annoyed by the tinnitus. It is said that he committed suicide 
on account of the depression caused by this state of his ears. 
There can be no doubt but that this symptom is one of the most 
distressing that can befall a patient, and that in some cases it 
is the provoking cause of suicide. Again and again, I have 
satisfied myself that the great depression, which is the rule in 
persons whose hearing is impaired, was due entirely to the 
aural disease. 

Dr. O. D. Pomeroy, 1 of this city, examined sixty lunatics at 
Blackwell's Island Lunatic Asylum, and he found disease of the 
ear in many of those who suffered from what may be called 
aural hallucinations, although not in so large a proportion as 
stated by Schwartze and Koppe. 

Dr. C. E. Wright 2 published a case of a patient in the In- 
diana State Asylum for the Insane, who attempted to destroy 
herself by putting a steel button in her ear. The patient was 
discharged from the hospital, as having recovered her reason, 
but became nervous and despondent, until she was relieved by 
the removal of the button ; and a dread of insanity and of sud- 
den death, from which she suffered, then also disappeared. 

Troltsch speaks of confusion of the intellect, an inability to 
keep up a connected line of thought, as a subjective symptom 
of chronic aural disease, and I am enabled to verify this opinion. 
Over and over again, have patients with chronic disease of the 
middle ear, not suffering from pain, but from tinnitus, volun- 
tarily informed me that these noises, together with the impair- 
ment of the hearing, had a great effect upon their mental 
powers. On the other hand, I have seen cases where most suc- 
cessful men, such, for instance, as distinguished general officers 
in the army, and celebrated writers, have suffered from boy- 
hood with chronic inflammation of the middle ear and tinnitus 
aurium. 3 

The sounds in the ears, of which patients speak, are vari- 
ously described; some speak of a ringing of bells, which is per- 



1 Transactions of the American Otological Society, Fourth Year, p. 40, 

2 Indiana Journal of Medicine, "November, 1871. 

3 The late Dr. George M. Beard, has often told me of the tinnitus aurium with 
which he was affected. He had chronic non-suppnrative inflammation and described 
the noises in his head, in graphic style. They never, how ever, dampened his eheert'ul 
and humorous temperament 



346 TINNITUS AURIUM. 

haps the most aggravating form ; others have likened them to 
the murmur of trees, the hum of a tea-kettle, etc. Wilde is un- 
doubtedly correct in stating that the descriptions which patients 
give of the noises depend to a certain degree upon their fancy, 
their graphic power of explanations, and not unfrequently upon 
their rank of life and the sounds with which they are most fa- 
miliar ; thus he says : " Persons from the country or rural dis- 
tricts draw their similitudes from the objects and noises by 
which they have been surrounded, as the falling and rushing of 
water, the singing of birds, the buzzing of bees, and the waving 
or rustling of trees ; while, on the other hand, persons living in 
towns, or in the vicinity of machinery or manufactories, say 
that they hear the rolling of carriages, the hammerings, and the 
various noises caused by steam-engines. Servants almost in- 
variably add to their other complaints that they suffer from the 
ringing of bells in their ears ; while, in the country, old women 
much given to tea-drinking sum up the category of their ail- 
ments by saying that ' all the tea kettles in Ireland are boiling 
in their ears.' " No description of tinnitus aurium has ever sur- 
passed this one given by the great Irish observer. 

Tinnitus aurium is usually, although not always, a subjec- 
tively disagreeable symptom. Sometimes, however, it is not 
unpleasant to the patient, but it may accompany its subject as 
a pleasing musical concert. One of my patients, a young wo- 
man having tinnitus aurium as one of the symptoms of disease 
of the middle ear, kept a record for me of what she heard "in 
her head." 

February 13th. — Morning, C sharp, B flat, F sharp in right ; 
B in left. Night, E flat, C flat. 

February 14th.— Morning, E flat, C flat. Night, C sharp, B 
flat, F sharp. 

February 15th.— Morning, C sharp, B flat, F sharp. Night, 
C sharp, B flat, F sharp. 

February 16th. — Morning, C sharp, B flat, F sharp. Night, 
F sharp, E flat. 

February 17th.— Morning, E, C sharp, A. Night, E>, B, G, 
and so forth. 1 

Mr. Hinton 2 regarded tinnitus of a distinctly musical char- 
acter as a sign of nervous affection. One man spoken of by him 
was subject to sudden attacks of loss of hearing with singing 
noise, and also complained of dimness of vision. " Dark specks " 
were found upon the yellow spot. 

1 American Journal of the Medical Sciences, Vol. LXVIIL, p. 378. 

2 The Questions of Aural Surgery, p. 286. 



TINNITUS AUEIUM. 347 

Thus far I have been speaking- of subjective tinnitus, of 
sounds of which the patients give graphic descriptions, as being 
in their head, but of which the physician can know nothing ex- 
cept from these narrations. There is also an objective tinnitus 
aurium, usually intermittent in character and of a crackling 
nature. It is a rare symptom, and is always, as far as my ex- 
perience goes, very distressing to the patient. In one case, 
where a crackling and intermittent sound could be heard in the 
ear both by myself and the patient, the victim was driven into 
insanity and suicide by failure to get relief from it. This kind 
of noise in the ear is, I believe, dependent upon abnormal action 
of the tensor tympani, stapedius, or of the muscles of the Eus- 
tachian tube. I have known the symptom to disappear when 
the disease in which it arose — sub-acute catarrh — was relieved, 
but I have never known it to be benefited by any treatment 
when it occurred in conjunction with chronic naso-pharyngeal 
catarrh. 

Ordinary tinnitus should also be distinguished from a venous 
murmur transmitted from the jugular vein, which runs just 
beneath the floor of the cavity of the tympanum, and from the 
pulsating sound of the internal carotid as it winds through the 
apex of the petrous bone. This variety of tinnitus, is not neces- 
sarily connected with impairment of hearing, but is usually 
dependent upon anaemia or aneurism. 

The cause of the common form of subjective tinnitus aurium 
has been much discussed, but we are yet without any exact 
knowledge as to how it is produced. We do know, however, in 
what diseases it is usually found as a constant symptom. It is 
a very common, almost universal, attendant of chronic non- 
suppurative disease, and is most distressing in the proliferous 
form, when it forms the chief complaint of the unfortunate sub- 
jects. It also occurs in inspissated cerumen, in acute and sub- 
acute catarrh of the middle ear. It is not a prominent symp- 
tom in chronic disease of the labyrinth, or at least patients do 
not speak of it as being very hard to bear. 

Keasoning from the standpoint of the diseases in which the 
ordinary subjective tinnitus aurium is generally present. I have 
always considered it to be a symptom indicating pressure upon 
the vessels of the tympanum and labyrinth. Dr. Theobald ' 
seeks to explain the nature of tinnitus aurium by stating that it 
is due to "the existence of vibrations exerted in the walls of the 
blood-vessels of the labyrinth by the friction attending the cir- 
culation of the blood." I have found the reasoning of Field, of 



Transactions of the Medical and Chirurgioal Faculty of Maryland, April, 1875. 



348 CAUSES OF TINNITUS AURIUM. 

London, as to the cause of tinnitus very clear. He believes, as 
I do, that any impairment of the "pressure equilibrium" of the 
ear will be a cause of tinnitus. He has illustrated this thesis in 
a very satisfactory way. He remarks, abnormal pressure of the 
air in the external auditory canal producing increased pressure 
upon the endolymph of the cochlea will cause it, just as a sud- 
den striking of the key-board of a piano will set in "discordant 
vibration every note that it is capable of producing." Thus anae- 
mia and hyperaemia, Mr. Field observes, are powerful agents 
in modifying pressure equilibrium. Overfilled arteries and ar- 
terioles cause undue pressure on the peri- and endo-lymph and 
excite tinnitus. 

The tinnitus from quinine, salicylic acid, wintergreen, and so 
forth, may thus be explained. 

The decrease in the pressure of the blood-vessels in anaemia is 
also called in by Mr. Field, to explain tinnitus, and he gives the 
familiar illustrations of chlorotic young women, and patients 
who have suffered from great hemorrhages, as examples, to 
which may be added the singing in the ears experienced in syn- 
cope. I have long taught this theory of increased pressure, as 
the chief cause of subjective tinnitus aurium, and I am very 
glad to give a new circulation to Field's more amplified and 
better view of the disturbance of pressure equilibrium, as that 
which causes an abnormal vascular tension or lack of tension, 
and thus becomes the essential cause of tinnitus. ' 

Patients suffering from chronic catarrhal inflammation of 
the middle ear usually speak of the throat as troubling them 
quite as much as their ears. In many cases, however, they say 
nothing whatever about the throat, and even if asked about it, 
they will insist that it is quite well, although they will often 
admit that they raise a great deal of mucus in the morning, and 
that they have sore-throat very often. The greater number of 
patients with aural catarrh complain greatly of the condition of 
their pharynx and nostrils, and, under the stimulus of the ad- 
vertisements and books of charlatans, have generally very much 
to say of the catarrh, although they do not always trace a con- 
nection between the throat disease and that of the ear. 

There are very many other symptoms than these which have 
just been enumerated — feelings of fulness, confusion of intellect, 
vertigo, tinnitus, and neuralgic pains — of which patients with 
chronic catarrh of the middle ear often complain ; but they are 
not always dependent upon the aural disease, and the examiner 

1 London Medical Times and Gazette, June 8, 1878. Also, Diseases of the Ear, 
p. 208 et seq. 



PROLIFEROUS INFLAMMATION. 349 

may often throw many of them out of consideration, and bring 
the patient back from the long story of headaches, dyspepsia, 
and so forth, by asking whether, after all, if the ear and throat 
were well, they would not consider themselves in good health, 
when an affirmative answer is often given. 



SUBJECTIVE SYMPTOMS OF PROLIFEROUS INFLAMMATION. 

If we now turn to the picture of the subjective symptoms of 
what I term proliferous inflammation, we shall find them much 
less positive than those of the catarrhal form. Some of the 
patients have no subjective symptoms at all, except that of loss 
of hearing, which is of course an objective symptom as well. 
They have no sore-throat, no increase of the secretion of the 
pharynx or nostrils. Others, again, complain of feelings of ful- 
ness in the ears, and nearly all of tinnitus aurium. Indeed, I 
think the tinnitus is apt to be more troublesome in the prolifer- 
ous than in the catarrhal form. This we should suppose a priori 
to be the case, because the causes in the proliferous variety of 
middle-ear disease are constantly acting, while in the catarrhal 
variety the temporary removal of the increased secretion will 
often greatly alleviate this symptom, and sometimes completely 
remove it. The origin of this form of aural trouble cannot be 
traced back to infantile earaches, frequent coryzas, or to naso- 
pharyngeal catarrh. It is a peculiarly insidious affection, one 
which is usually under full headway, and which essentially im- 
pairs the function of hearing long before the patient is aware 
that he has any affection of the ears. The pathology of the dis- 
ease, of which an account will be given a little later on in the 
discussion of this subject, explains something of this insidious 
character. 

Catarrhal and proliferous inflammation may exist in one and 
the same ear, when it will be impossible to make a differential 
diagnosis, yet in the greater number of cases the line can be 
drawn between the two forms. 

Chronic catarrh of the middle ear, as well as proliferous in- 
flammation may also exist in connection with chronic disease of 
the labyrinth. The practitioner should not be too ready to eon- 
elude that the predominant or chief affection in a given ease o( 
impairment of hearing, is to be found only in the middle ear. 
simply because the patient has a naso - pharyngeal catarrh, 
and is hard of hearing. There are means to distinguish these 
affections, of which I shall speak fully before finishing this 
subject. 



350 DISEASE OF NERVE AND MIDDLE EAR. 



OBJECTIVE SYMPTOMS OF CATARRHAL INFLAMMATION. 

The objective evidences of chronic catarrhal inflammation of 
the middle ear, may be classified as follows : 

1. Impairment of hearing. 

2. Changes in the membrana tympani. 

3. Imperfect action and changes in the structure of the Eus- 
tachian tube. 

4. Capability of hearing better in a noise than in a quiet 
place. 

5. Better conduction of sounds through the bone than through 
the air. 

6. Naso-pharyngeal inflammation. 

If we exclude the latter, we have also the objective symptoms 
of chronic proliferous inflammation. 

The Differential Diagnosis of Chronic Nonsuppurative Inflam- 
mation of the Middle Ear from a Disease of the Labyrinth. 

The tuning-fork is one of the most useful means of diagnos- 
ticating an affection of the middle ear, from one of the labyrinth. 
In the catarrhal form of disease its use is not as essential as in 
the proliferous, for the good reason that the subjective and ob- 
jective symptoms together, form such a decided picture that it 
would be hard to fall into error as to the seat or nature of the 
trouble. But, in the proliferous form, both sets of symptoms are 
often of such a negative character, that without the tuning-fork 
we are sometimes in doubt as to whether we are dealing with 
a peripheric or central disease. 

Starting from the well-established fact, that, if the auditory 
canal of a person having healthy ears be closed by the finger, or 
in any other way, the sound made by a vibrating body is heard 
more distinctly on the side of the head where the ear is closed, 
it has been shown that, in most diseases of the auditory canal 
and middle ear, such vibrations are more distinctly felt on the 
affected side, or, if one be diseased, that they are heard more 
distinctly on the side of the ear affected, and on which the tick- 
ing of a watch or the sound of conversation is not as well heard. 

The differential diagnosis between a chronic proliferous in- 
flammation of the middle ear. and an affection of the acoustic 
nerve is important and often difficult. It is important, for while 
local treatment of a proliferous inflammation of the middle ear 
is often beneficial, such a treatment applied to an affection of the 
nerve is always useless and generally harmful. Certainly it adds 



DISEASE OF NERVE AND MIDDLE EAR. 351 

to the annoyances of the patient. The differential diagnosis is 
sometimes difficult, because a secondary affection of the nerve 
often exists in connection with chronic non-suppurative inflam- 
mation of the middle ear. But, as I hope to show in this chap- 
ter, and in those upon "Diseases of the Internal Ear," some of 
these difficulties have been removed, so that we may now more 
readily make a diagnosis than was formerly possible. The tests 
which were formerly exclusively used to differentiate between 
diseases of the middle ear and of the nerve, and which have 
just been described, I have of late, as was said in chapter sec- 
ond, practically abandoned, not because they were not valu- 
able, but because the test of the aerial and bone conduction is 
much more easy to carry out, and is more certain. When both 
ears are diseased, it is often difficult for a patient to say whether 
or not he hears a vibrating tuning-fork better in one ear than the 
other, but the most stupid person can easily determine whether 
a vibrating tuning-fork is heard better through the air, when 
held in front of the meatus, or through the bone when placed 
on the mastoid process. Now I believe it is a rule without 
exception, that when the tuning-fork C is heard louder and 
longer through the bones than through the air, the predomi- 
nant disease is one of the external or middle ear. Of course, the 
external ear may be readily excluded or included, by ocular ex- 
amination. There may, however, be predominant disease of the 
middle ear, when through any cause, — wax in the canal, mucus, 
blood, serum, or pus in the tympanum,— abnormal pressure is 
made upon the peri- and endo-lymph, and yet the tuning-fork be 
heard better through the air. When the pressure is removed, 
if there be remaining disease of the middle ear, the tuning-fork 
C will be heard better through the bones. This is beautifully 
shown in the examination of boiler-makers, who become hard 
of hearing from their noisy occupation, and acquire disease of 
the nerve. They are of course also liable to disease of the canal, 
such as inspissated cerumen. Before the wax is removed in 
certain cases, the bone conduction is better, but on removing 
this, the hearing power remains impaired, but the tuning-fork is 
heard, as it always is heard in disease of the nerve, better and 
longer through the air. The table showing the results of exami- 
nation of boiler-makers in the chapters on "Diseases of the In- 
ternal Ear" will show this. 

The only difficulty then, in the test with the tuning-fork is 
that we cannot always tell on the first examination, when the 
tuning-fork is heard better through the air. whether this be due 
to pressure upon the labyrinth from temporary causes, or to in- 
trinsic disease of the nerve. 



352 AERIAL AND BONE CONDUCTION. 

By temporary causes, I mean an accumulation of wax in the 
canal, or of mucus, pus or blood in the tympanum. These being 
present, pressure may be made upon the labyrinth, and cause the 
aerial conduction to be temporarily better than that through the 
bones. We cannot, therefore, in some cases when we find bet- 
ter aerial conduction, determine at once, that it may not be due 
to disease of the canal or middle ear. We may be obliged in 
some such cases, to make more than one examination before we 
come to a positive conclusion. With better bone conduction, 
however, we have no such difficulty — and with constant use of 
the tuning-fork in diagnosis, we become more and more confi- 
dent and exact in our deductions. 

Some years since, I suggested a new test with the tuning- 
fork, which is stated in the following proposition. Generally 
true, as I believe it will be found, I have abandoned its use also 
for the simpler test of the aerial and bone conduction. 

If, under the same conditions of a sound ear on one side, while 
the hearing power of the other is impaired, the tuning-fork be 
not heard better in the worse ear, even if the meatus be stopped 
by the finger or the like, there is disease of the labyrinth, the 
acoustic nerve or brain. 

I employed the older tests, until constant examinations have 
convinced me, that the one as to the aerial and bone conduction 
is the most reliable and easiest to conduct of all those, that have 
resulted from Mtillers first experiments. 

I now use the tuning-fork simply to determine which is bet- 
ter, the aerial or the bone conduction. At my clinics, where I 
have a class of practitioners, I have invariably found that it is 
considered a simple and adequate test, by those who have seen 
it employed upon almost all kinds of patients. It is indeed a 
very simple thing to determine whether the vibrations of a tun- 
ing-fork are heard better through the air, or through the bones, 
and this is the gist of the test. In some cases it is well to also 
test the time during which the fork is heard. A simple way of 
doing this is to place it upon the bones, after the patient says it 
is no longer heard through the air, or vice versa. In many in- 
stances, however, a stop-watch and a test of the duration in each 
position, are necessary to an accurate idea as to the relative in- 
tensity of aerial and bone conduction. 

After having, in the doubtful cases of the proliferous variety, 
settled the fact as to whether we have an affection of the middle 
ear or of the labyrinth, the ticking of the watch and ordinary 
conversation become the natural tests as to the impairment of 
hearing. 

The watch is an inadequate test, for the reason that has 



POWER OF HEARING WATCH AND SPEECH. 353 

already been mentioned in the introductory chapter, that is, 
that some persons can hear a watch quite a number of inches 
from the ear, while thev hear conversation very badly. Lucae 
explains this fact by saying, that speech is made up of an ex- 
tremely complicated system of tones, and sounds of most differ- 
ent tone-heights, while the tick of a watch is made up of a class 
of very high tones which are usually better heard than low ones. 
But, there are cases where speech is heard much better than the 
tick of a watch. Careful observation of the lips of the speaker, 
by the person whose hearing is defective, may have something 
to do with explaining this class of cases. Excluding these, how- 
ever, I have become convinced that there is disease of the acous- 
tic nerve, when conversation is heard relatively better than the 
tick of a watch. I have come to this conclusion, because I have 
almost invariably found this symptom in connection with others 
that indicate an affection of the nerve. 

In commenting upon Lucae's explanation of the occasional 
disproportion, between the power of hearing the watch and con- 
versation, Politzer remarks that he believes it to be due to the 
fact that in anchylosis of the stapes, the membrane of the fen- 
estra rotunda often remains normal. If this be not thickeneg 1 , 
he goes on to say, that simple tones and noises may be trans- 
mitted without difficulty through the air of the tympanum to 
the membrane of the fenestra rotunda, while speech can only 
be perfectly transmitted through the ossicles. " The greater the 
impediment to the conduction of sound through the ossicles, the 
greater is the impairment of hearing for speech." 2 This expla- 
nation is perfectly consistent with my experience, for I have 
found an adhesive process in the tympanum more destructive to 
the hearing power for speech, that is for ordinary conversation 
than a disease of the labyrinth. Deaf mutes, who are usually 
deaf from adhesive inflammation of the middle ear. are striking: 
examples of persons deaf to speech, although they may hear 
sounds and noises through the bones. 



BETTER HEARING IN A NOISE. 

Persons affected with disease of the middle ear. uncomplicated 
by secondary disease of the labyrinth, hear better in a noise than 
they do in a quiet place. This is true of acute, sub-acute, and 
chronic disease. But it has only been especially commented 
upon when occurring in chronic non-suppurative cases. Con- 
sequently it has of ten been mistakenly assumed, that it is always 



1 Lehrbm-h, p. 394. 
23 



354 BETTER HEARING IN A NOISE. 

a very unfavorable symptom. It is not necessarily so, but inas- 
much as it is chiefly observed in cases that are actually incur- 
able, it is not at all strange that it has been so considered. I 
believe that important deductions can already be made as to 
the situation of the nature of the lesion that causes the impair- 
ment of hearing in a given case, from this symptom, and I also 
hope that from a right interpretation of it, may yet come an 
invention to improve the hearing power of a large class of per- 
sons. For these reasons, I shall be quite full in my account of 
this symptom. 

In the collected works of Doctor of Medicine Thomas Willis, 
published in Amsterdam, a little more than two hundred years 
ago. in a cha'pter upon the sense of hearing, and in a paragraph 
relating to deafness caused by relaxation of the membrana tym- 
pani, there is an account of a somewhat famous woman, who 
could only hear the voice of her husband when a servant was 
beating a drum in the same room. 1 

Although this passage is often alluded to, it is seldom quoted. 
No apology will, I think, be required for a translation of it. 

"Although hearing is very little produced by the membrana 
tympani as compared with the proper organ of the sense, yet it 
so far depends upon it, that deprivation or diminution of that 
sense not infrequently proceeds from its injury or impeded action. 
Indeed, a certain kind of deafness occurs, in which, although the 
patients seem completely to lack the sense of hearing, yet so 
long as a great din, such as that of bombardments, or of chimes 
of bells, or of drums, resounds about their ears, they take in 
distinctly the conversation of those about them, and answer 
questions intelligently, but, upon the ceasing of such tremendous 
uproar, they immediately become deaf again. I once had it from 
a trustworthy man, that he had been acquainted with a woman, 

1 Archives of Otology, vol. xii , No. 2, June, 1883. The original reads as follows: 
Quanquam auditus a tympano, velut propria sznsionis organo, minime peragiivr, 
tamen iste in tantum ab hoc dependet, ut non raro d tympani actions kesa> aut impedita 
sensus illius privatio, aut diminutio proctdat. Enimvero surditatis species quondam occur- 
rit, in qua licet affecti au itus sensi penitus carere rideantur, quam-diu tamen ingens 
fragor, uti bombardarum, campanarum, aut tympani belliei, prope aures circumstrepit, 
adstautium colloquia distincte capiunt, et interrogatis apte respondent, cessante, rero im- 
mani isto strepitu, denuo statim obsurdescunt. Accepi olim a xiro fide digno, se muli- 
erem quce licet surda fuerat, quousque tamen intra conclave tympanum pulsaretur, verba 
quaems dare audiebat ; quare maritus ejus Tympanistam pro fervo domestico conducebaU 
ut illius ope, colloquia interdum cum uxore sua haberet. Etiarn de alio Surdastro mild 
narratum est, qui prope campanile degens, quoties una plures campana> resonarent, wcem 
quamxis, facile audire, et non alias potuit. Proculdubio liorum ratio erat, quod tym- 
panum in se continuo relamtum, soni veliementioris impulsu ad debitam tensitatem, quo 
munere suo aliquatenus de fungi pot uerit, cogeretur. 



BETTER HEARING IN A NOISE. 355 

who, although she was deaf, would, nevertheless, distinctly hear 
whatever was said so long as a drum was beaten within the room, 
and consequently her husband employed a drummer as a house- 
hold servant, in order that by his aid he might occasionally hold 
conversations with his wife. I have also been told of another 
deaf person, living near a bell-tower, who could easily hear any 
voice whenever the bells were pealing — but not otherwise. Doubt- 
less the reason of these things is, that the membrana tympani, 
habitually relaxed when left to itself, was forced by the shock 
of a sound much more intense than usual, to a state of tension 
sufficient to enable it to perform its function in some degree.'' ' 

In the two centuries that have followed the narration of 
Willis's observations, the symptom of hearing better in a noise, 
has not only been given the name of the author, and is known 
in our time as Paracusis Willisiana, but the facts as stated by 
the author, have in turn been denied and affirmed, and while 
many have admitted the truth of the observations, and have 
conceded that there are some persons with impaired hearing 
who hear better in a noise, Willis's explanation of the phenom- 
enon has been rejected by them. The writers on aural medi- 
cine who allude to it at all, are by no means agreed upon the 
facts nor upon their explanation. Wilde 2 admits the credibility 
of Willis's cases, and argues against the notion of Kramer, that 
the auditory nerve became so excited by these loud sounds as to 
be able to do its work better. Wilde explains the phenomenon 
by reference to the state of the membrana tympani, and says 
that it is remarkable that it does not occur in cases where that 
structure has been in whole or in part removed. Later on, I 
shall show that Wilde was in error in thinking that it could not 
occur when there was a hole in the drum-head. 

Troltsch 3 says : "These statements (as to hearing better in a 
noise) are founded, as a rule, upon a want of exact observation, 
as well as upon self-deception." He then relates one of Willis's 
cases, and also one reported by an author named Fielitz. The 
latter was that of a deaf son of a shoemaker, who could only 
hear conversation in the room, when he stood near his father 
and the latter pounded sole leather upon a large stone. This 
same boy, heard well in a mill when it was in action. 

I cannot agree with Troltsch, in his idea that the symptom of 
hearing better in a noise is not a common one. As T have said 
on several occasions, my own experience has proven that it is a 



1 Opera Omnia, Amstelsedamia , apud Henrionm Wetstenium Pars physiologic*, 
Cap. xiv , p. 09. -' Aural Surgery, English edition, p. OS;'. 

8 Troltsch: Lehrbuch, Sechste Ausgabe, p. 858, passim. 



356 BETTEE HEAKHNTG IN A NOISE. 

very frequent one. Rau, 1 like Kramer, believed that better hear- 
ing in a noise depends upon excitement of a torpid acoustic 
nerve. In somewhat poetic style, he says: "If the auditory 
nerve be awakened from its slumber by loud talking, the patient 
will momentarily hear even words spoken in a low tone very 
well. This sometimes goes to such an extent, that the hearing 
is temporarily restored to a considerable degree by a loud and 
regular sound, for example, during the pealing of bells, drum- 
ming, a ride in a rattling wagon, or the like." Burnett, 2 of our 
own country, is positive that the symptom is a real one, but con- 
fines it to the later stages of chronic aural catarrh, "when the 
condition of the tympanum has become dry or sclerotic, or when 
the thickening of the mucous membrane has become great in 
the moist form." 

Dr. E. E. Holt 3 doubts if, in any case the hearing-power is im- 
proved by noise, and he states that, so far as he is aware, no one 
has "ever made a careful investigation to ascertain whether the 
claim of such persons was a real one or not." 

In the first edition of this book, and in all the subsequent edi- 
tions, I related from my personal experience the case of a mail 
agent, on one of our railways, who, although very hard of hear- 
ing in a quiet place, could hear very well in his car amid the 
noise of a train. I have had frequent opportunities to study this 
case, and there is no question as to the facts. No person who 
did not know of this gentleman's infirmity, would ever suspect 
him of impaired hearing while conversing in the din of a rapidly 
going train of railway carriages. But the instant he reached a 
quiet place, it was with the greatest difficulty, that he could hear 
loud conversation specially addressed to him. 

Politzer, has no doubts as to the existence of these cases, and 
confirms what was stated by me years ago, "that the patients 
can understand speech during such noises much easier, and at 
a much greater distance, than people with normal hearing." 4 
Politzer, however, states that he has observed this symptom 
"almost exclusively in the incurable forms of affections of the 
middle ear." 

I have known of two cases where this symptom occurred, in 
patients who regained their hearing perfectly. While the symp- 
tom frequently accompanies incurable disease of the middle ear, 
I believe it is a very frequent symptom in sub-acute cases, when 
both ears are affected. Of course, it would not be observed in 
disease of one ear only. I also have two cases under observation 
in which the drum-heads are entirely, or nearly removed, and 

1 Lehrbuch, p. 292. * Treatise on the Ear, p. 386. 

3 Transactions of American Otological Society, 1882. "Lehrbuch, p. 233. 



BETTEH HEARING IN A NOISE. 357 

yet these patients hear well in a noise. One of these, I published 
in the fourth edition of this book. While the occurrence of the 
symptom in sub-acute cases disposes of the notion that hearing 
better in a noise implies an incurable disease, the fact that it 
also may exist when the membrana tympani is gone, shows that 
Willis's explanation of the phenomenon is not exclusively, if at 
all, correct. I have never yet seen the symptom except in dis- 
ease of the middle ear. I believe it never occurs except in cases 
where the nerve is sound. I have looked over my cases with 
great care as to this point, and I have yet to see a patient who 
had, as I supposed, disease of the acoustic nerve, and who yet 
heard better in a noise. If this be true, the theory of an extra- 
ordinary excitement of the nervous apparatus, as a cause of the 
phenomenon, must be rejected. Buck and Politzer, explain the 
symptom by a reference to some effect upon the ossicula audi- 
tus, made by the great din. 1 This is the only theory, incomplete 
as it is, which fulfils the conditions made by such cases as those 
just mentioned, where, although the membranse tympani were 
gone, the ossicula were intact. How the ossicles are affected is a 
problem yet to be solved, but when it is solved, it will be possible 
to invent an instrument to enable those deaf from disease of the 
middle ear, to hear conversation not only in a noise, but in the 
quiet of an ordinary room. This latter will, certainly, not be a task 
beyond the capabilities of a physicist of the nineteenth century. 
The statement, that these cases rest upon inexact observa- 
tions, will soon be disproven by a ride of a few miles in a rail- 
way carriage or in a clattering wagon, with a person deaf from 
disease of the middle ear, to ordinary conversation in a quiet 
place. Examinations of boiler-makers, or of those who suffer 
from affections of the ^acoustic nerve, will, however, be disap- 
pointing, and will lead, as in Dr. Holt's paper, from which I 
have already quoted, to a doubt in the mind of the observer as 
to the reality of the symptom. I now quote one of the cases in 
which the hearing was better in a noise, and which was one of 
subacute catarrh of the middle ears, from which the subject 
fully recovered under my observation. The writer of his own 
case is now a practising physician in this city. At the time of 
the occurrence of the disease he was a boy in school, aiul 1 re- 
ported his case, except as to the symptom now under discussion. 
in the American Journal of the Medical Sciences'' and in the first 
edition of this book. Dr. B writes to me as follows : 

With regard to the disputed faet of many deaf persons bearing conversa- 
tion better in noisy places, I wish to give in brief my experience. For several 

1 Medical Record, July 5, 1875. Vol. Ill, p. ol. 



358 BETTEE HEAKING IN A NOISE. 

years previous to my sixteenth, I had been much troubled with varying degrees 
of deafness, due, as I then heard and now understand, to acute catarrh of the 
middle ear, complicating general pharyngeal catarrh. At school I was at a great 
disadvantage, suffering at times great embarrassment on account of my limited 
hearing. Living far up-town, I was in the habit of being driven home or to the 
doctor's by my mother. When surrounded by the noise of wheels and glass, I 
invariably had occasion to request a moderation of her voice ; and she not in- 
frequently made the remark : " How well you hear in the carriage ! " Further- 
more, on several occasions, my parents were surprised to find that they could 
not safely carry on a confidential conversation requiring only sound enough to 
suffice their own hearing powers, while in a quiet room their talk would have 
been unintelligible. 

This is only an echo of the experience of many deaf people I have ques- 
tioned on the subject. 

The other case was that of a student of seventeen years of 
age, and is so similar to the one just given, that I simply allude 
to it. As I have already intimated, the power of hearing better 
in a noise is a different subject from that of the effect of certain 
noisy occupations upon the ear. Patients like my friend, the 
mail agent, may travel for years in the din of a train, and al- 
ways find their hearing improved and not decreased, so long as 
it depends upon disease of the middle ear. Neither do I know 
of any cases of deafness that have been caused by such occupa- 
tions. But although there is a class of patients who have been 
made deaf by noise, often confounded with those whose impair- 
ment of hearing has resulted from catarrh, they should be en- 
tirely disassociated from them. Boiler-makers, and those who 
become deaf from an exposure to the continuous shock of loud 
sounds, suffer a lesion of the acoustic nerve. These patients do 
not hear better in a noise, but they have a source of relief in 
quiet places, and, like ordinary people, they hear better away 
from the din that is such a comfort to a person deaf from many 
forms of disease of the middle ear. 

I must confess to have assisted in the creation of confusion 
in our ideas as to hearing better in a noise, and the effects of 
noise upon the ear. In 1874, in one of the editions of this work, 
I gave the results of my examinations of a certain number of 
boiler-makers, and I incidentally assumed that they heard better 
in the noise of their occupations. When the paper by Dr. Holt, 
to which I have referred, appeared, I found that he denied the 
correctness of my main conclusions ; that is, that the impair- 
ment of hearing in boiler-makers is generally a result of a lesion 
of some part of the labyrinth, and that, besides his doubt that 
any deaf person, much less boiler-makers, ever heard better in 
a noise, he was inclined to attribute their impairment of hearing 
to a disease of the middle ear. I then made a new series of ex- 



BETTER HEARING IN A NOISE. 359 

animations upon boiler-makers, assisted by Dr. J. B. Emerson. 
As a result of these recent investigations, which were under- 
taken with the much better means of a differential diagnosis 
between diseases of the middle and internal ear, now at our 
command, I find that I cannot agree with Dr. Holt's conclu- 
sions, except in one particular, and that is the one just men- 
tioned, i.e., that boiler-makers do not hear better in a noise. 
This incidental statement made by me, I now find to be entirely 
incorrect. But that boiler-makers do suffer from a lesion of the 
internal ear, and not of the middle ear, in so far as they have a 
peculiar affection from their occupation, I do not' think admits 
of a doubt. The very fact that they do not hear better in a noise 
is an incidental proof that they suffer from a lesion of the laby- 
rinth. Boiler-makers, like men in other occupations, often have 
impacted cerumen, and occasionally catarrh of the middle ear, 
but the disease caused by their occupation, " boiler-makers' 
deafness," in my opinion, is easily shown to be a disease of the 
labyrinth. Other occupations of a similar nature, that is, occu- 
pations amid continuous concussions, undoubtedly cause the 
same lesion. A recent visit to- an establishment where two 
engineers were employed for the production of electric light, 
showed me that they had become somewhat hard of hearing, 
since they had been engaged in an occupation exposing them to 
the sound of regular concussions from the striking of metallic 
plates together. 

The confusion which I assisted in producing upon the sub- 
ject was not, however, as regards the seat or cause of the aural 
lesion, but as regards the ability of these workmen to hear better 
in the din in which they labor. It will perhaps be remembered 
that it has just been stated that those who hear better in a noise 
always suffered from some form of disease of the middle ear. 
When some years of observation had convinced me of the uni- 
formity of this rule, I was puzzled to account for my cases of 
so-called boiler-makers' deafness, which, in my paper upon this 
subject, I had assumed were also improved by being in a noise. 
I had said : "It will be observed that the subjects of it (boiler- 
makers' deafness) hear very well in the tremendous din of a 
boiler-shop, while they are quite deaf in an ordinarily quiet 
place." 1 This remark, I am constrained to say, although in 
the other editions of this book, is strikingly incorrect. Boiler- 
makers, as we should naturally believe, are no exception to the 
rule, that those who have disease of the nerve hear worse in a 
noise. Boiler-makers hear so badly in their shops that they 



Treatise on the Ear, third edition, p. 510. 



360 BETTER HEARING IN A NOISE. 

have a language of signs that is quite elaborate, called a "boiler- 
makers' language." They hear no better in a noise than do 
people with sound ears ; on the contrary, they hear better in a 
quiet place. 

If, however, a person deaf from disease of the middle ear, 
who hears better in the noise of a railway train, enters a boiler- 
shop, that person will hear better than the boiler-makers, or 
than persons with sound ears. 

It is only very recently that I have been able to send a pa- 
tient suffering from chronic disease of the middle ear, who heard 
well in a railway carriage, to a boiler-shop. I had predicted, 
that although boiler-makers with disease of the acoustic nerves 
and persons with sound ears, hear very badly in the dreadful 
din, such a patient would hear well in such a place. 

The patient whom I sent is a lady of about thirty years of 
age, who has had chronic disease of the middle ears, of the pro- 
liferous form, for many years. She cannot hear the watch at 
all, and conversation only when directed into the ear, and then 
with difficulty. In the cars she hears very well. She only hears 
the tuning-fork by bone-conduction. Her account of the experi- 
ment is as follows : 

w I went with my husband (he has excellent hearing) this 
afternoon to the boiler-shops of the Dickson Co. (Scranton, Pa.), 
where the noise is perfectly deafening. I could distinctly hear 
what my husband said, although he purposely spoke in a low 
tone, while he could not hear a word I said, unless I put my 
mouth to his ear and screamed. I think, perhaps, cars and 
boiler-shops are the places for me to live." In a subsequent note 
she informs me that she could not hear the watch tick, although 
she hears conversation so easily. 

In this case it will be noted that the improvement does not 
depend upon the loud tone of the speaker. 

The fact that most patients suffering from disease of the 
middle ear hear better in a noise, especially that of a railway 
car, I find as a result of a series of examinations extending over 
many years, and embracing several hundreds of cases. Wher- 
ever this symptom is not present, I have found that either the 
disease was primarily or secondarily one of the labyrinth or 
acoustic nerve. 

I have gone with such patients to a train in motion, and I 
have always found their statements correct. From hearing a 
voice with difficulty directly in the ear, they have been enabled 
to hear it twenty feet, that is to say to hear conversation at that 
distance and with ease. In my experience they do not always 
hear a watch tick farther, but most of these marked subjects 



BETTEE HEARING IN A NOISE. 361 

hear a watch a very short distance, if at all, in a quiet place. 
There is, I think with Politzer, sometimes an improvement in 
this respect also. 

I have also made many tests in my clinic, in the following 
manner, for the purpose of demonstrating this phenomenon to 
my class. I have first tested the perception of sound by aerial 
and by bone conduction. I have then made the room as quiet 
as was possible, and tested the capability of the patient for hear- 
ing conversation. Then the room has been made as noisy as 
could readily be done by moving chairs on the tiled floor, rap- 
ping on walls and tables, and so forth, and I have again tested 
the hearing. Invariably have I found, that when the tuning- 
fork was perceived on both sides better through the bones, that 
the power of hearing was better in a noise, and also that the re- 
verse was true. The result may be formulated as follows : 

Bone-conduction better. 
Better hearing in a noise. 
Disease of middle ear. 

Aerial conduction better. 
Worse hearing in a noise. 

Disease of acoustic nerve, either primary or 
secondary. 

This symptom would often be found in acute disease of both 
sides did such diseases last long enough to admit of proper tests. 
To say that the whole explanation is to be found in the fact that 
the voice is raised when in a noise, is to forget that even in a 
quiet place, with just such an elevation of the voice, these pa- 
tients do not hear as well as they do in the noise. Besides, the 
elevation in the voice is usually only slight, and sometimes there 
is none at all. 

I have yet to find a case where a mistake was made in a de- 
liberate statement by a patient, that conversation was heard 
better in a noise. When the symptom does occur, it is so 
marked that no mistake can be made. When a patient does 
not know whether he does or does not hear better in a noise, we 
may assume that he does not, and when he does not. the ease 
will, I think, always be found to be one in which the nerve is 
somewhat involved. 

From all the observations I have been able to make upon 
this subject, I think I am justified in drawing the following 
conclusions : 

1. There is a large class of people suffering from impairment 



362 CHANGES IN MEMBRANA TYMPANI. 

of hearing in quiet places, who hear very acutely and with 
comfort amid a great din or noise. 

2. The disease causing the impairment of hearing thus re- 
lieved is situated in the middle ear. It is usually observed in 
the chronic, non-suppurative form of disease of the middle ear, 
but it may also be found in acute or sub-acute catarrh of this 
part, as well as in a chronic suppurative process with loss of the 
whole or a part of the membrana tympani. 

3. The proximate cause of this phenomenon is not as yet posi- 
tively known. It is probably to be found in some change in the 
action of the articulations of the ossicula auditus. 

If a physicist can give us an instrument which, being placed 
in the auditory canal, will produce sound enough to act upon 
the ossicles, as does a great noise in a room, or the noise of a 
railway train, we shall have found magnifying lenses for the 
deaf. 

CHANGES IN THE MEMBRANA TYMPANI. 

I do not regard the appearance of the drum-head as posi- 
tively indicative of aural disease. In some few cases, we find 
the membrane in what may fairly be said to be a normal con- 
dition in appearance, and yet we may have a very great im- 
pairment of hearing, which the other objective symptoms as 
well as the tuning-fork, show to depend upon disease of the 
middle ear. These cases are not common, and then, if the 
loss of hearing is great, we may conclude that the alterations 
in structure are chiefly upon the inner or labyrinthine wall 
of the cavity of the tympanum. I think, however, that we 
very rarely find an absolute sinking inward of the membrane, 
unless attended by some impairment of hearing. A sunken 
drum-head, that is, one in which the head of the malleus stands 
out like a miniature button, while the whole membrane seems 
collapsed and sunken, is pretty fair evidence of the existence 
of adhesions in the cavity of the tympanum, and of impairment 
of hearing. 

The first question in studying the membrana tympani is, 
very naturally, what is the appearance of a normal one ? The 
introduction of Troltsch's method of examining the membrana 
tympani, has done more than anything else to stimulate the 
study of its character. The ordinary anatomical text-books 
give no true idea of this beautiful and important part. Such 
authorities on aural disease as Kramer, Wilde, and Toynbee, 
give descriptions of it that are far from exact. To Troltsch 
and Politzer we are indebted for such perfect descriptions, that 



CHANGES IN MEMBRANA TYMPANI. 363 

we now have a complete guide to the changes that may occur 
upon it. 

In order to determine what may fairly be considered a nor- 
mal membrana tympani, I have examined a number of what 
may be considered healthy ears. The persons whose ears were 
thus examined were not aware that they had ever had any kind 
of aural inflammation, even in childhood. They did not suffer 
from naso-pharyngeal catarrh, and never had suffered from it. 
The hearing distance, as tested by the watch, was normal, and 
the tuning-fork was heard equally well on both sides of the 
head. Such persons are very rare in any community, and con- 
sequently I have only as yet examined seventeen membranes 
belonging to this class. From these cases, and the observations 
of others, I determine that the color of the membrane may vary 
from a neutral gray to a dark blue ; but it is rather more in- 
clined to a gray than to a blue. The lustre and transparency 
vary exceedingly ; the membrane may be very brilliant and 
transparent, so that the stapes is seen through it, and it may be 
quite dull and hazy in appearance. 

The light spot at the end of the malleus is usually triangular 
in shape, although not always. It is, perhaps, always present 
in some form if the hearing be normal. The head, handle, and 
short process of the malleus are plainly visible. There may be 
opacities at the margin of the membrane, where, as Troltsch 
showed, the mucous membrane is thickest. The gray color may 
be modified by a delicate pinkish injection along the periphery 
of the membrane and handle of the malleus. 

It is not uncommon to find chalky spots or points of calcare- 
ous degeneration in the membrana tympani. They are found 
not only in the ears of persons with impaired hearing, but also 
in those whose hearing power is acute. Undue weight should, 
therefore, not be attached to these appearances. 

Yon Troltsch x seems to have been disposed to regard these 
calcareous formations as connected with high degrees of im- 
pairment of hearing, but I have not found this to be necessarily 
the case. Politzer 2 regards them as the products of suppurative 
processes that have run their course. In some cases, as we 
know, such inflammatory affections are perfectly recovered 
from, and if the calcareous degeneration do not occur on an 
important part of the membrane, it probably will produce no 
impairment of hearing of itself. 

Moos has proved by one case which he observed, that a cal- 
careous degeneration may occur in the course of a non-sup- 

1 rolitzer: The Membrana Tympani, p. 58. - Loo. oil 



364 CHANGES IN. MEMBRANA TYMPANI. 

purative process. This case was that of a woman more than 
seventy years of age, who had chronic catarrh of the middle 
ear. 

Calcareous degenerations, as shown by the microscopic ex- 
aminations of Politzer, usually occur in the fibrous layer. Where 
the deposit was not very thick, the integument was quite easily 
separated from the calcified parts. The mucous layer was a 
little more adherent. In some cases both the external and mid- 
dle layers were involved in the calcific process. Politzer once 
found a true osseous deposit, together with the calcareous de- 
generation, in one of his cases. Black or dark brown pigment 
was also found by him and fat-globules everywhere. 

An acute catarrh of the middle ear in childhood, is sufficient 
to change the color or curvature of the membrana tympani, and 
thus render it impossible to say that we are dealing with a nor- 
mal membrane. The membrana tympani of the child, differs 
from that of the adult, in being more transparent, while it is 
rather of a yellowish tinge than gray, and the handle of the 
malleus is not as distinctly seen. 

Politzer has shown, in his work on this membrane, that the 
triangular spot of light, which is one of the chief points for 
study in this part, is due to the manner of the reflection of light 
from its surface, and the factors which cause this reflection 
have been fully detailed in the chapter upon " The Anatomy of 
the Middle Ear." 

Politzer * believes that we can form no conclusions as to 
changes in the cavity of the tympanum and membrana tym- 
pani, from alterations in the size and shape of the light spot ; 
but I cannot endorse this view. In the first place, if changes 
have taken place in the outer layer, or layer of epidermis, the 
reflecting power of the membrane is nearly removed, and there 
is no light spot. Its absence certainly indicates changes in the 
drum-head. Again, if it be smaller than usual, or if it can be 
changed in form by the Valsalvian experiment, or by other 
methods of inflating the middle ear, I think we may draw quite 
positive and valuable conclusions as to the traction exerted by 
the malleus, and as to the inclination of the membrane. I do 
not deny that we may find an irregular or small light spot on a 
person with normal hearing power ; but I believe that such a 
state of things is rare, and that its shape and size will be found 
to be, in the majority of cases, a pretty fair guide in a general 
way, as to the loss of function. From the notes of ninety-four 
ears affected with chronic non-suppurative inflammation of the 

1 Tie Membrana Tympani, translated by Mathewson and Newton, p. 8. 



TRIANGULAR LIGHT SPOT. 365 

middle ear, seen at the Manhattan Eye and Ear Hospital, and 
recorded by Dr. D. Webster — 

In 59 the light spot was present. 



35 

9 

44 

2 
4 



absent. 

normal. 

smaller. 

larger. 

divided (i.e., 2 or more light spots existed) 



In the last hundred cases of chronic catarrhal inflammation 
of the middle ear, that I have seen in private practice, the fol- 
lowing notes as to the light spot were made : 

Well shaped 16 

Small 48 

None 17 

Two 1 

Interrupted 8 

Fairly shaped 9 

Very broad 1 

100 

The experiments of Magnus in compressed air, which have 
been alluded to in the chapter on "Injuries of the Membrana 
Tympani," also prove that the non-existence of the light spot 
does show, that the membrana tympani is forced or drawn 
inward. 

CHANGES IN MOBILITY OF MEMBRANA TYMPANI. 

If a person, having normal hearing power, forces the air 
into the cavities of the tympanum by* a prolonged inspiration 
and expiration, with the nostrils closed, he has performed the 
Valsalvian experiment for testing the permeability of the Eus- 
tachian tubes, and, on examination during this act. we rind that 
the membranes moved outward and then inward. This change 
takes place, in a healthy membrane, chiefly at the apex of the 
light spot, or extremity of the malleus ; but it may occur in 
other parts, especially in Shrapnell's membrane. In the ca- 
tarrhal form of affections of the middle car. the mobility of the 
drum-head is not affected to any extent. It may be even pre- 
ternaturally movable. In the proliferous variety, adhesions are 
apt to occur between the malleus and the membrane, ami be- 
tween the other ossicula, and these will seriously affect the 
normal movements of the drum-bead and the chain o( bones. 
It is true, however, that mere swelling of the membrane, such 



366 MOBILITY OF MEMBRANA TYMPANI. 

as obtains in the second stage of the catarrhal form, will, to 
some extent, affect the motions of these parts. 

It should not be thought, that the middle ear is in a normal 
condition, because a drum membrane moves. The membrane 
may move well, and yet the most serious changes may have 
taken place in the cavity behind it. Patients who suffer from 
impairment of hearing have pretty generally learned the Val- 
salvian test or experiment, and when they are so deaf as not 
to hear ordinary conversation at all, and have been so for 
years, they will often triumphantly, and with great skill, show 
the examiner how well they can blow air into their ears, as evi- 
dence that there can't be very much the matter with them after 
all. The promulgation among the laity and profession of the 
valuable character of this experiment has harmed many ears. 
It is an experiment simply. Its chief value belongs to the ob- 




Fig. 83. — Siegle's " Otoscope " with Ely's Attachment of a Syringe. 

server. It is an abuse of it to make it a method of treatment. It 
can be theoretically demonstrated that it is even a somewhat, 
although slightly, dangerous experiment to persons at all dis- 
posed to congestion of the head and neck ; but this danger is not 
great enough to lead the practitioner to wholly abandon it as a 
means of treatment, were it not, as I believe, almost useless 
therapeutically, and dangerous to the integrity of the tension of 
the membrana tympani. I very often see patients who have 
learned this method of treatment, and, having believed that no 
harm could ensue from a very frequent performance of the ex- 
periment, have been in the habit of inflating the membrana 
tympani several times a day. A membrane that has been thus 
treated becomes very flaccid, and flaps to and fro, at every swal- 
lowing motion. 

Siegle's instrument, a representation of which is here given, 
enables us to form pretty accurate notions of the mobility of the 
membrane. The air may be exhausted by means of the lips, 



CHANGES IN EUSTACHIAN TUBE. 367 

while the membrane is carefully watched for its movement, or a 
syringe may be used, such as Dr. Ely attached to the instrument, 
tare should be taken that the speculum, as it should be called, 
fit accurately in the auditory canal, so that exhaustion of the 
air may actually occur. Of course, the otoscope must be used to 
examine the drum-head through the glass of the speculum. 

CHANGES IN THE EUSTACHIAN TUBE. 

Having considered the appearance of the drum-head in cases 
of chronic non-suppurative inflammation of the middle ear, we 
have next to examine the Eustachian tube and pharynx, and 
note the changes which appear there. At this point the boun- 
dary line may be distinctly drawn between the catarrhal form 
and the proliferous form of inflammation. In the former class 
of cases, the pharynx and Eustachian tube show marked evi- 
dences of morbid action ; while in the latter there are scarcely 
any changes in the pharynx, and often no very striking ones in 
the Eustachian tube. The pharynx, in a true case of catarrhal 
inflammation of the middle ear, is found in one of the following 
conditions : 

There may be great swelling of the pharynx and of the ton- 
sils, with or without increase in the amount of secretion. There 
may be, however, excess of secretion, without any considerable 
swelling. In such cases the patient is usually very conscious of 
the trouble in his throat. He may not be aware of any pharyn- 
geal affection, and yet have a pharynx that is considerably 
relaxed and swollen. If these two symptoms be not present to 
any marked extent, we usually find minute round elevations 
scattered over the surface, or grouped in an arch under the 
uvula. These constitute the disease known as pharyngitis gran- 
ulosa. The pathological condition is a stoppage of the secre- 
tions, and subsequently hypertrophy of the structure. This 
affection is called by some authors chronic follicular pharyn- 
gitis, and its more advanced stages glandular hypertrophy ; but 
I prefer the simple nomenclature of pharyngitis, in the stage 
of increased secretion and swelling, and granular pharyngitis, 
when these characteristics of the inflammation are less promi- 
nent, but where the granulations or hypertrophic glands are 
very marked in appearance. If the tonsils arc not enlarged, 
they often exhibit, by a jagged appearance, the evidence of for- 
mer disease. 

Dr. Wilhelm Meyer, of Copenhagen, in 1873' brought to the 



Archiv fur Ohrenheilkunde, Bd. I., Neue Polge, p. '234, Bd. II.. pp. 189, 241, 



368 



ADENOID GROWTHS. 



particular notice of the profession, a disease of the nasopharyn- 
geal space, which, although known by reports of isolated cases, 
seems never to have been adequately studied until Meyer began 
his investigations. "Adenoid growths in the naso-pharyngeal 
space " is the title of Meyer's first paper upon the subject. These 
growths must be known to every practitioner who sees much of 
naso-pharyngeal disease, but they do not seem to be as common 
in our country as in Denmark. They are developed in the course 
of a chronic inflammation of the pharynx. They are of two 
varieties in shape, follicular or tongue-shaped. The first variety 
is more common. These cases have been described by Czermak, 
Tiirck, Semeleder, Voltolini, and Lowenberg. The latter author 




Fig. 84. — Pharyngitis Granulosa. This engraving was made from a drawing, by Mr. G. C. 
Wright, of the pharynx of a young lady, who had suffered for many years from a chronic sup- 
purative inflammation of the middle ear ; but it is a fair type of some of the worst cases of 
granular pharyngitis, as seen in chronic catarrhal inflammation. 

speaks of them under the head of granular pharyngitis, and 
until Meyer's papers were published they were generally and 
properly enough comprehended in this title. The microscope, 
according to Meyer, after the examination of forty different 
specimens, showed that these growths were of the same structure 
exactly as the so-called "adenoid tissue" of His. When these 
adenoid growths or vegetations are found in the pharynx, the 
surrounding parts are intensely injected, swelled, and secrete a 
delicate, often greenish mucus abundantly. The velum is most 
swelled, so that it is very much enlarged. The mouths of the 
Eustachian tube in this disease, according to Meyer, are very 
often red and swelled, and covered by mucus so tenacious, that 
it is very difficult to remove it by syringing. In some few cases 
the mouth of the tube is narrowed to a mere fissure. Most of 






ADENOID GROWTHS. 369 

my readers can verify this picture of Meyer's from cases they 
have seen. Of 175 cases observed by Meyer, 130 were associated 
with disease of the ear. By far the greater number were cases 
of catarrh of the middle ear, while suppurative inflammation of 
the middle ear was found in one-fourth of the cases. Of 1083 
cases of aural disease observed by Meyer in 1809, 18?0, 1871, and 
1872, adenoid vegetations in the naso-pharyngeal space were 
found in about seven and a half cases in a hundred. Meyer 
cautions us against ascribing too great an importance to these 
growths as a cause of aural disease, for he recognizes the fact 
that many of these cases never come under professional observa- 
tion and treatment, because the subjects of them are sometimes 
troubled only with a catarrhal throat, for which they do not con- 
sider treatment necessary. I have often been surprised at the 
number of cases of naso-pharyngeal disease of a severe form in 
which there is no disease of the ear. The intensity of a naso- 
pharyngeal inflammation seems often to stop at the mouths of 
the Eustachian tubes. A patient may have chronic naso-pha- 
ryngeal catarrh all his life and never suffer from aural disease. 1 
There is no doubt since Meyer's investigations, that adenoid 
vegetations should be distinguished from simple granular pha- 
ryngitis, with which it may coexist. These growths affect the 
physiognomy and the speech, just as do enlarged tonsils. Pa- 
tients speak "through their nose," say "dose" for "nose," "sogh" 
for "song," and so forth. The resonance of the voice is very 
much impaired by enlarged tonsils, and granular pharyngitis, as 
well as by general hypertrophy of the naso-pharyngeal mucous 
membrane. 

Examination by the finger passed behind the palate is very 
useful in making a diagnosis of adenoid vegetations. The rhino- 
scope is of course a valuable aid, but they can usually be detected 
by simple inspection of that portion of the naso-pharyngeal space 
to be seen when the mouth is opened. 

Meyer's experience, that adenoid vegetations are chiefly seen 
in youth, is verified by all observers. They are frequently asso- 
ciated with cleft palate, according to Meyer, and Smith and Coles. 
quoted by him {Lancet, 18G9, p. 772). Of the prognosis and treat- 
ment, something will be said in subsequent pages. 2 

The rhinoscope will be found a valuable assistant in a few 
cases for an exact diagnosis of affections of the naso-pharyngeal 

1 Beverley Robinson seems also to have noted this. Transactions o\' American 
Laryngological Association, 1883. 

- Meyer's first observations were published in 1868, in Danish, and copied in 
Schmidt's Jahrbnch for 1809, and as ho says with candor, even before this, other ob- 
servers had published striking cases. They escaped general notice, however. 
24 



370 EUSTACHIAN CATHETER. 

space. As a matter of fact, however, very few of us who treat 
a great deal of aural disease, make much use of the rhinoscope. 
It is only in exceptional cases that we find that its revelations 
compensate for the time employed. 

As I have already intimated in the second chapter, I use 
much smaller catheters than those usually employed. Large 
catheters are very difficult of introduction, and their use is gen- 
erally very painful to the patient. I think one-half the difficul- 
ties encountered by the inexperienced practitioner in the use of 
the Eustachian catheter, will vanish, if he will he content with 
hard-rubber catheters of small calibre and curve. 

Very many of the patients who suffer from pharyngitis and 
naso-pharyngeal inflammation, scarcely speak of it when asking 
advice in regard to the disease of the ears, and it is only on 
close questioning that they will admit that they are annoyed by 
the accumulation of mucus in the throat, causing frequent ex- 
pectoration, hawking, and the other symptoms of chronic pha- 
ryngeal catarrh. At other times the catarrh, as they term it, is 
the great burden on their minds, and they talk freely of the 
stuffed feeling in the head, and describe their symptoms in a 
graphic style, that has been obtained by a diligent perusal of 
the advertising columns of the daily newspapers. 

The Eustachian catheter is a very valuable means of diag- 
nosticating not only the changes in the cavity of the tympanum, 
but also those in the naso-pharyngeal space. In passing this 
instrument through the nostrils it should always be used as a 
sound, and the condition of this portion of the mucous tract 
carefully noted. The inferior meatus is often found swollen and 
even granular. In some cases nasal polypi may exist. There may 
also be an abnormal position of the septum which renders the 
canal very narrow and irregular. The manner in which the air 
passes through the catheter into the tube is deemed by many as 
of much importance in the diagnosis of chronic catarrhal or 
plastic inflammation. The passage of a full and strong current 
almost necessarily precludes the idea of any considerable change 
in the calibre of the Eustachian tube, unless it be atrophy of its 
tissue. The mere fact that air can be made to enter the tube, 
either by the Yalsalvian experiment, the Eustachian catheter. 
Toynbee's or Politzer's method ; in other words, the fact that 
the Eustachian tube is open, so that the patient perceives the 
fulness in the ears, which shows that a column of air has been 
forced against that already in the middle ear, is no evidence 
whatever, that the ear is in a healthy condition. In my own 
experience, closure of the Eustachian tube is one of the rarest of 
conditions. I mean by closure such a state of things, that, by 



EUSTACHIAN CATHETER. 371 

trial of the catheter and Politzer's method, the air cannot be 
made to enter the ear. 

The two nostrils often differ very much in size. This differ- 
ence is usually due to a deviation of the septum to one side or 
the other, in consequence, perhaps, of an injury received when 
the patient was young, and the bone was soft. In some very 
rare cases not even the smallest catheter that can be made, can 
be passed through the nostril of one side. For such cases the 
catheter has usually been made longer, and introduced through 
the opposite nostril ; but Dr. Noyes, 1 of this city, thinks that this 
method is not reliable, because by it the air simply passes "across 
tho axis of the Eustachian tube, and if it pass up the tube at all, 
it can only do so after being reflected from the outer wall of the 
trumpet orifice." 

Dr. Noyes recommends a catheter of double curve for such 
cases. The following are his directions for using it : " When in- 
troducing the catheter, it is needful to keep the front close to the 
septum, as well as to the floor of the nostril. Arrived at the pos- 
terior edge of the septum, the beak should wind closely around 
it, curving obliquely across, and turning upward, so as to point 
toward the Eustachian orifice." 

Of late years I have scarcely found any cases where a small 
hard-rubber catheter, after the pattern figured in the second 
chapter, could not be used, and I have ceased to use the catheter 
of double curve, or to pass one from the opposite nostril. 

In order to test the permeability of the tubes, the subsequent 
examination of the membrana tympani and the patient's own 
sensations become important evidences. The membrana tym- 
pani may become reddened by the mere application of instru- 
ments to the external canal, and to the mouth of the tube, so 
that we must be careful to exclude such sources of error. 

The diagnostic tube of Toynbee, by means of which we listen 
to the sounds of the air passing through the tube up to the drum- 
head, is also thought by many to be of assistance in determining 
the patency of the tube and the size of the cavity of the tym- 
panum. 2 Kramer claimed to determine, by the use of the diag- 
nostic tube, the character of "exudation" and the width of the 
tube. If there is a piercing (durchgehendes), near, rattling, vesic- 
ular sound, he then diagnosticated the existence of a free exu- 
dation. If, however, a sonorous, near, vesicular sound, it is 
proof that there is no free exudation ; if there is a distant, muf- 
fled, vesicular sound, then we are deviling with sub-mucous exu- 



1 Transactions of the American Otologioal Society, L870. 

2 See engraving on page To. 



372 DIAGNOSTIC TUBE. 

dation, which is united to free exudation, and so on. I only 
quote these from the last edition of Kramers book, to show to 
what lengths a man may go in riding a hobby; for Kramer's 
hobby was the diagnosis of the affections of the middle ear. by 
the sounds heard through the diagnostic tube, caused by blow- 
ing through his catheters. 

The true value of the diagnostic tube is only in connection 
with the other means that have been mentioned, the appearance 
of the membrana tympani, and the patient's own sensations. 

I think the diagnostic tube could well be dispensed with in 
aural practice. Whether an Eustachian tube is pervious or not, 
may be learned much more readily than by listening with the 
diagnostic tube. The old ideas as to the importance of mere 
permeability of the tube, have been properly lost sight of, in 
the study of the nature of the inflammatory changes in the 
calibre of the tube and in the tympanic cavity. I am unable to 
get much light as to these points from the use of the tube. Yet 
I must admit, that some of my colleagues, whose opinion I value 
very highly, still use it. 

PATHOLOGY. 

After the clinical investigations of Kramer and Wilde, the 
first great advance that was made in otology were the dissec- 
tions of Toynbee. The museum of preparations illustrative of 
diseases of the ear, in London, is a memorial to Joseph Toynbee, 
that will be as enduring as scientific truth. From the time of 
Toynbee until now, the dissection of ears of those who were 
known to be deaf continues : and from the labors of Von Troltsch, 
Schwartze, Voltolini, Hinton, Gruber, Orne Green, Moos, 1 and 
others, we have verified on the dead bodies diseases that have 
been diagnosticated in the living one, but in many cases, we 
have only learned, from the inspection of the ears of the ca- 
daver, what is probably the condition of ears in life. 

The pathological appearances in chronic catarrhal inflamma- 
tion are — 

1. Collections of mucus or serum distending the cavity of the 
tympanum. 

2. Thickened mucous membrane. 

3. Filling up of the cavity by lymph. 



1 A Descriptive Catalogue of Preparations Illustrative of the Diseases of the Ear. 
London, 1857. Archiv fur Ohrenheilkunde, Bd. I.-V. Monatsschrift fur Ohrenheil- 
kunde. Guy's Hospital Reports. Gruber's Lehrbuch. Transactions American Oto- 
logical Society.- Moos' Klinik der Ohrenkrankheiten. Wendt, quoted by Schwartze, 
Pathology of the Ear, p. 106. 



PATHOLOGY. 373 



PATHOLOGY OF PROLIFEROUS INFLAMMATION. 

In the form of inflammation that shows a higher formation 
than the catarrhal, there are changes which may have resulted 
directly from the increase of secretion ; but the stage of catarrh 
having completely passed over, or, in some cases, never having 
existed, these pathological appearances may be properly classed 
together as evidences of what I have ventured to designate the 
proliferous form. They are : 

1. Connective-tissue formations in the cavity of the tym- 
panum. 

2. The mucous membrane of the tube covered by dense fibrous 
tissue. 

3. Hypertrophy of the bony walls of the tube. 

4. Obstruction of the tube and cavity of the tympanum by 
dense fibrous tissue. 

5. The stapes bone completely and firmly anchylosed to the 
margin of the fenestra ovalis. 

6. An exostosis on the inner surface of the neck of the mal- 
leus. 

7. Malleus and incus anchylosed together. 

8. Firm bands of adhesions in the mastoid cells. 

9. False membrane on the tendon of the tensor tympani 
muscle. 

10. Partial obliteration of the cavity of the tympanum, by 
adhesions of the membrana tympani to the labyrinth wall. 

11. Hyperostosis of the petrous bone, and anchylosis of both 
stapes. 

12. Atrophy and fatty and fibrous degeneration of the tensor 
tympani. 

13. Thickenings and deposits of lime, and of large round cells 
in the connective-tissue stroma of the fenestra rotunda. 

14. Pseudo-membranous growths, sometimes filling the whole 
cavity with an irregular network, and sometimes covering the 
fenestra rotunda, and the tympanic orifice of the Eustachian 
tube. 

These are actual appearances of individual cases, taken from 
Toynbee's catalogue and from the writings of the other authori- 
ties whom I have mentioned; some of thorn are perhaps con- 
sequences of suppurative inflammation, although 1 have been 
careful to exclude all cases in which there was less of the mem- 
brana tympani, or other positive evidence of a suppurative 
process. 



374 NON-SUPPURATIVE INFLAMMATION — CAUSES. 

Gruber's 1 account of the pathology of otitis media hyper- 
trophica is, that, "from some cause or other, there is first a 
great hyperemia with distention of the membrane, and in part 
the new formation of blood-vessels, and increase of the inter- 
cellular fluid. The connective-tissue corpuscles are increased. 
The tissue of the inflamed mucous membrane is less moist than 
in the catarrhal form. The new formations or new elementary 
formations go on to a higher development. The most various 
adhesions may occur, or a soft connective substance appears 
which is either evenly spread over the whole portion that was 
originally inflamed, and thus leads to hypertrophy of the mu- 
cous membrane, or it may go on to granular formation. Many 
of these new formations may also undergo regressive meta- 
morphosis — they may undergo molecular disintegration, become 
fatty, and be absorbed." 



CAUSES. 

I have endeavored, in recording the histories of about forty- 
eight hundred cases of aural disease observed in private prac- 
tice, to give the probable remote and proximate causes. These 
are only to be obtained by a strictly observed system of cross- 
questioning, since by far the greater number of patients ascribe 
their disease to causes which are certainly very remote, if not 
doubtful, and to others which have certainly had no influence. 
Thus patients will assert that their loss of hearing results from 
cold, when they cannot remember that they ever had a severe 
cold affecting the ears, but they conclude that it must have been 
a cold ; others, again, declare that their throats have always 
been well, that they seldom require to use a handkerchief, and 
yet an examination will reveal a bad condition of the nasopha- 
ryngeal mucous membrane. 

Judging as well as I am able, from my experience in public 
as well as private practice, I am disposed to consider the follow- 
ing as among the most probable causes of chronic non-suppura- 
tive inflammation of the middle ear : 

Remote. — 1. A feeble state of the system, due, for example, to 
inherited or acquired syphilis, phthisis pulmonalis, and so forth. 

2. Defective hygienic management, e.g., neglect of bathing, 
want of exercise in the open air, lack of proper food, care as to 
dress, and so forth. 

Proximate. — 1. Repeated attacks of acute catarrh of the phar- 
ynx and middle ear, a disease popularly known as earache. 



Leln-bucli der Olirenlieilkunde, S. 516. Wien, 1870. 



NON-SUPPUBATIVE INFLAMMATION— CAUSES. 375 

2. Nasopharyngeal inflammation. 

3. Diseases of the lungs and bronchial tubes. 

These proximate causes are chiefly to be made out in the 
catarrhal form of chronic inflammation, while in the prolifer- 
ous form, the practitioner is often greatly in doubt, as to what 
may have been the origin or exciting cause of the insidious 
affection which goes on so steadily to change of structure and 
loss of function. Indeed, we are often obliged to be content to 
acknowledge the fact of change of structure without being able 
to definitely assign a cause for it. Why the changes that make 
up a true case of proliferous inflammation, or one of a bastard 
form in which the proliferous element predominates, continue 
to advance in spite of treatment and of proper hygienic manage- 
ment, is one of the most disheartening problems that a practi- 
tioner who treats aural disease attempts to solve. It is not 
strange, that cases of insidiously advancing impairment of hear- 
ing, dependent upon illy defined, but positive causes, have ex- 
cited the minds of physicians to adopt even what may appear to 
be fanciful means for their cure. 

The history of coryzas and earaches, and of chronic sore- 
throats, is usually distinct enough in chronic catarrhal inflam- 
mation, and even if there be no such history, then the appear- 
ances of the pharynx, and the results of tactile investigation of 
the tubes, are sufficient to allow us to determine just what kind 
of a process has been going on. 

It would be interesting to accurately trace the origin of these 
proximate causes. We should find, I think, that the most of 
them were due to neglect, or improper management ; for ex- 
ample, the heads of some children are oftentimes vigorously 
washed without being thoroughly dried ; they are allowed to 
remain in water unduly long ; their legs and chests are left un- 
covered in weather in which strong men are clad in beaver- 
cloth, and women in furs ; they play about the streets, and sit 
down, when tired and warm, on the damp and cold stone steps 
of city houses ; they are held thoughtlessly by an open window 
on a cold day ; they are warmly clad by day, but insufficiently 
covered at night ; in short, the temperature of the body is not 
properly regulated, and a pharyngeal catarrh passes in an in- 
stant to the tympanic cavity, where it is an acute catarrh. If 
the acute catarrh does not go on to suppuration, it is half re- 
covered from under the use of anodynes applied to the outer 
surface of the drum membrane ; in which and the tympanic 
cavity a thickening is left which forms a good basis for a case 
of gradual and mysterious middle- ear trouble, and with no 
known cause. In large towns where the system of drainage or 



376 NON-SUPPURATIVE INFLAMMATION — CAUSES. 

sewerage is sometimes imperfect, foul air may be forced back 
through the water-pipes, and becomes a cause, often unsus- 
pected, of catarrhs of the worst type. 

With older people a slight and neglected coryza or pharyn- 
gitis is followed by a fulness in the ears, that " will wear away," 
and which does wear away in part ; but if it occurs in persons 
who have no good hygienic habits in such matters as bathing, 
eating and drinking, and so forth, it leaves behind a degree of 
hyper-secretion or proliferation, which, as has been said, is the 
foundation for repeated attacks, and, finally, of permanent 
thickening and of adhesions. 

The syphilitic catarrh of infants and young persons is the 
frequent cause of an affection of the middle ear, which, unlike 
its frequent companion, interstitial keratitis, is one of the worst 
forms of disease in the obstinacy with which it resists all treat- 
ment. The eyes may, and generally do, get well ; but, if once 
the tympanic cavities be attacked, intra-auricular adhesions 
occur, the membrana tympani is drawn inward, the nerve is 
secondarily involved, and the loss of hearing often becomes al- 
most complete. 

There are no peculiar aural symptoms, by which we may 
positively distinguish a case of chronic disease of the middle 
ear that was caused by syphilis, from one occurring in a non- 
syphilitic patient. Yet we may say, in general, that a syphi- 
litic diathesis seems to cause the proliferation of tissue to be 
more rapid and less amenable to treatment. Schwartze be- 
lieves that the pathological change in these syphilitic cases is a 
periostitis, and this view seems to be correct. 

Just how it is, that pregnant women are so often affected by 
a proliferous inflammation of the middle ear, I am unable to 
say ; but it is a fact, that many women have told me, that they 
traced their impairment of hearing to their first pregnancy, and 
that they became worse at the birth of each child. I am now in 
the habit of warning such patients that great attention should 
be paid to their throat and ears, by means of gargles and Po- 
litzer's method, during the period of utero-gestation. It is the 
proliferous form of inflammation, and not the catarrhal, which 
I have usually observed during such cases. 

Proliferous inflammation of the middle ear is often produced 
by cerebro spinal meningitis. In scarlet fever and measles, we 
are more apt to have suppuration than in the former disease. 
It has been supposed that disease of the internal ear, is more 
frequently produced by cerebro-spinal meningitis, than that of 
the tympanum and Eustachian tube. This, I think, is an error ; 
but for a fuller discussion of this subject, I refer the reader to 



NON-SUPPUEATIVE INFLAMMATION — CAUSES. 377 

the chapter on " Deaf-Muteism." Parotitis also is a cause of 
disease of the middle ear, but more frequently, perhaps, it af- 
fects the labyrinth, if not exclusively, certainly in connection 
with disease of the middle ear. This subject also will again be 
alluded to. The excessive use of quinine may also, in rare in- 
stances, cause incurable disease of the middle ear. 

The causes given by patients themselves, taken from my 
note-book, are as follows: "Stuffy sensations in the head;'' 
"going in the water very frequently;" "severe colds in the 
head;" "when a child, the ears would stop up, and would not 
hear well for a few days." The first manifestation was "a roar- 
ing noise heard at night;" "chronic sore-throat;" "great deal 
of earache;" "all the colds from which I suffer are in the head;" 
" excessive grief;" "a sound like that of locusts was the first in- 
dication of trouble;" "by accident discovered that I could not 
hear from one ear;" "I have always had a great deal of sore- 
throat;" "diphtheria;" "typhoid fever." One patient gave a 
graphic account of a gradual loss of hearing from proliferous in- 
flammation, in the following words : "Ten years ago I observed 
that I could not hear the church-bells, and in four or five years 
it began to be difficult for me to hear conversation." Another 
ludicrously attributed his chronic catarrh to exercise upon a 
gymnastic pole. Another was quite sure that it resulted from 
great mental anxiety. These are fair specimens of the causes 
assigned by the patients or their friends for cases of the variety 
of aural disease now under consideration. Some of them are 
far from being true causes, although the most of them may be 
admitted as having at least placed the system in such a condi- 
tion that catarrhal disease or proliferation of tissue was likely 
to result. It is undoubtedly true, that any great mental depres- 
sion may cause an attack of pharyngitis in a person disposed to 
it, and that long continuance of such a state of mind will make 
such an affection incurable. 

We may, perhaps, sum up our knowledge of the causes of 
chronic non-suppurative disease of the middle ear, by stating 
that they are such as dispose to inflammation of mucous mem- 
brane. Our increased knowledge of the pathology of this tissue, 
will serve us in good stead in investigating the affections oi a 
part which is thoroughly lined by it. 



CHAPTER XIV. 

CHBONIC NON-SUPPUKATIVE INFLAMMATION OF THE MIDDLE 

EAB— {Continued). 

Treatment o: the Catarrhal and Proliferous Forms. — Constitutional and Hygienic Appli- 
cations to the Naso-pharyngeal Space. — Nasal Douche. — Cases of Acute Aural Disease 
caused by its Use. — Gruber's Method of Cleansing Nares. — Politzer's Method. — 
Anatomy of Nasal Cavities. — Nebulizers. — Faucial Catheters. — Eemoval of the 
Tonsils. — Treatment through the Eustachian Tube. — Air. — Steam. — Vapors. — 
Fluids. —Bougies — Electricity. — Death from Improper Use of Catheter. — Dura- 
tion of Treatment, — Prognosis. 

In the preceding chapter a table was given, showing at about 
what time in the history of their disease, the patients from whose 
cases it was made up, consulted the writer. It may be safely 
asserted, that the most of these persons never underwent any 
serious or rational local treatment until that time ; so that we 
may assume that the greater number of persons in the United 
States who suffer from the form of disease under consideration, 
are in the habit of waiting for a period of from five to twenty 
years, before they attempt to get relief. 

We must certainly diminish the number of these cases before 
we can hope for brilliant results. The neglect of aural thera- 
peutics by the last and the preceding generation now recoils 
upon us. Patients come very late for advice about their ears, 
because they have been taught, not by the laity, but by wise 
and skilful physicians, that it is not prudent to meddle with the 
ear ; that they will outgrow its diseases, as soon as their con- 
stitution is invigorated ; if young girls, that, when the men- 
strual function comes on, their ears will rapidly recover, and so 
forth, while, during this time of delay, adhesions between the 
membrana tympani and the ossicula, and the walls of the cavity 
of the tympanum, have been forming, and hypertrophy of the 
mucous membrane and atrophy of the tendons of the intra-auric- 
ular muscles — in short, all the changes have occurred, that we 
have found may take place in the tympanum and drum-head. 

In one respect the treatment of a catarrhal non-suppurative 



NON-SUPPUEATIVE INFLAMMATION— TREATMENT. 379 

inflammation may be fairly distinguished from that of the pro- 
liferous form. In the catarrhal form we must give a great deal 
of attention to the naso-pharyngeal space, while in the other we 
scarcely need to treat it. Perhaps we may classify the treat- 
ment generally advised as follows : 

1. Constitutional and hygienic. 

2. Local blood-letting and counter-irritation. 

3. Applications to, and operations upon, the naso-pharyngeal 
space (chiefly applicable to the catarrhal form of the disease). 

4. Applications to the Eustachian tube. 

5. Applications to the cavity of the tympanum. 

6. Cutting operations upon the membrana tympani and the 
ossicula. 

In the text-books of Wilde and Toynbee (books that have 
deservedly had a wide circulation in this country, and have 
done much to call attention to the ear) constitutional remedies 
figure very largely in the treatment. The use of mercury and 
iodide of potassium is strongly insisted upon. We, of the pres- 
ent time, have grown very skeptical about the constitutional 
treatment of such affections as chronic catarrhal, and prolifer- 
ous inflammation of the middle ear. No thoughtful practitioner 
will attempt to disregard the general indications of a cachexia, 
or of a debilitated system, in which there is chronic inflamma- 
tion of the mucous membrane of the middle ear ; but the time 
has probably gone by when a person in fair health, suffering 
from chronic aural catarrh, and who has no constitutional taint, 
will be treated by alterative doses of the bichloride of mercury, 
followed by the iodide of potassium. Ample experience has 
shown that we can do nothing for these cases by such a treat- 
ment, and I may say, that it has been abandoned in the infirma- 
ries and hospitals, where large numbers of cases of aural disease 
are seen. The constitutional symptoms of the earliest stages of 
the disease were usually those of a coryza or acute catarrh, which 
finally settled down into an insidious and chronic process, when 
it has become impossible to trace the remote causes. 

Of late, Dr. Theobald, of Baltimore, has warmly advocated 
the constitutional treatment, that is to say, by internal medica- 
tion, of the form of disease now under discussion, as well as of 
chronic suppuration, and acute processes, but my opinions as to 
the general inefficacy of drugs, under the limitations 1 have 
given, have not changed since writing the above. Homoeo- 
pathic practitioners attach great importance to the internal ad- 
ministration of their peculiar medicines, in catarrhal and sup- 
purative inflammations of the ear, but they seem to use all the 
ordinary local means employed by the profession in general as 



380 NON-SUPPURATIVE INFLAMMATION — TREATMENT. 

well. Dr. Houghton ' recommends baryta muriatica, cotyledon 
umbilicus, iodine lachesis, and mercurius dulcis, nux vomica (in 
irritations of the mucous membrane of the middle ear, itching* 
in the Eustachian tube, provoking swallowing) for nonsuppura- 
tive inflammations of the middle ear as well as a host of rem- 
edies for the other diseases of the ear. As an example of what 
a belief in the specific value of internal remedies can produce, I 
may quote : "As a remedy cinchona proves curative in these two 
opposite conditions (congestion and anaemia), and acts upon both 
cochlea and semi-circular canals." . . . Gelsemium in con- 
junction with silicea, is said to have restored the hearing in 
forty-eight hours in a case simulating cerebro spinal meningitis 
on the one hand, and simple labyrinth vertigo on the other. 

In our northern climates, all people should wear flannel next 
the skin, winter and summer, of course varying the thickness 
according to the temperature and the strength of the individual. 
Thick boots in the winter, and overshoes in the wet, are also 
necessities for those who wish to avoid catarrhs. I also think 
that the temperature of a sleeping-room should not be allowed 
to go down at night to a point below 65° to 68° F. ; these rules are 
especially applicable to persons disposed to inflammations of the 
naso-pharyngeal space and ears. A whole chapter might easily 
be written upon this subject of personal hygiene. These hints, 
however, will be sufficient to induce the practitioner to give 
special attention to the subject in prescribing for chronic and 
advancing aural disease. 

The causes of these forms of disease suggest a kind of con- 
stitutional treatment, which should never be lost sight of. 
Everything that will render a patient more vigorous, and less 
likely to take cold, will assist materially in curing or alleviating 
a chronic aural catarrh. We shall thus find much to do, in the 
way of correcting improper habits of life, in regard to bathing, 
exercise in the fresh air, ordinary clothing, sleeping apparel, and 
the like. Hence the Turkish bath, 2 sponge-bathing, walking, 
riding, boat-rowing, the general application of electricity, the 
internal administration of iron, and so forth, become prescrip- 
tions which the otologist will be called upon to give very fre- 
quently, if he properly appreciates cause and effect. It is only 
against specific drugs, where there is no specific diathesis, 

1 Homoeopathic Therapeutics in Aural Surgery. 

2 The Turkish hath is one of the hest means of keeping the circulation so equahle 
that catarrhs do not readily occur. It is not a good plan, however, to allow the head 
to he wet, during the shampooing process that follows the hot-air hath, neither should 
patients disposed to aural disease, take the cold plunge which is often given at the ter- 
mination of the whole process. 



TREATMENT OF PHARYNX. 381 

against a routine system of prescribing a constitutional remedy 
in the vague hope that it may do good, that I have been speak- 
ing. 

The use of leeches in some cases of chronic catarrhal inflam- 
mations that have sub-acute tendencies, is occasionally of value, 
although they give no such marked relief as that which is 
experienced in acute inflammation. When there are decided 
symptoms of congestion, such as fulness and slight pain, a leech 
may be applied on the tragus once a week, for four or five 
weeks. Blisters are also of value in such cases. 



TREATMENT OF THE PHARYNX. 

The treatment of the pharynx may be classified as follows : 

1. Injections of the naso-pharyngeal space. 

2. Gargling. 

3. Cauterizations. 

4. Removal of the tonsils, large granulations, and of ade- 
noid growths. 

Injections of the naso-pharyngeal cavity by means of the 
naso-pharyngeal syringe, and by Davidson's double-bulbed syr- 




Fig. 85. — Posterior Nares Syringe. 

inge usually used for enemata, I have found very valuable in 
the treatment of chronic catarrhal inflammation. The solutions 
I use are common salt, permanganate of potash, gr. £ ad 3 j.. a 
saturated solution of chlorate of potash, tar-water benzoate of 
sodium, and so forth. Great masses of mucopurulent material 
are often dislodged by this treatment, even in cases where ordi- 
nary inspection does not show that any has collected. The 
nasal douche is very frequently used for the purpose of cleans- 
ing the naso-pharyngeal space, but it is a means of treatment 
that is attended with considerable danger to the ear. even when 
all proper precautions are taken. 

The posterior nares syringe is made of hard rubber. It is a 
very efficient and safe means of cleansing the pharynx and nos- 
trils. In eases of acute inflammation of the pharynx attended 
with considerable swelling, it should be used with care, or it 
will abrade and irritate the mucous membrane of the posterior 
pharyngeal wall. This abrasion may then lead to an extension 



382 NASAL DOUCHE. 

of the inflammation along the tube, to the tympanic cavity. In 
chronic cases I have never seen or heard of any harm being 
done by the posterior nares syringe. 

Davidson's syringe is also a safe and useful instrument for 




Fig. 86. — Davidson's Syringe, with a Nozzle to go below the Soft Palate. 

cleansing the nares. It may be used anteriorly or posteriorly. 
Of late years, I use it more than I do the posterior nares syringe. 



THE NASAL DOUCHE. 

I have published several cases that illustrate the dangerous 
consequences that may result to the ear from the use of the 
nasal douche, and I was the first writer to call attention to 
this subject. The appliauce is so convenient of application, 
and it is thought to be so thorough in its work of cleansing 
the nostrils and pharynx, that many are very loth to abandon 
it. I am of the opinion, however, that its use should be dis- 
countenanced by the profession. Various criticisms have been 
made upon the published cases of injury to the ear from the 
use of the douche, but I believe that they have been fully met, 
and that most of the otologists on this side of the water, are 
agreed that the nasal douche, even when employed with all 
proper precautions, has produced serious aural symptoms in 
quite a large number of cases. The harmful results are prob- 
ably due to the entrance of a large quantity of fluid, in a flood, 
as it were, into the cavity of the tympanum along the Eusta- 
chian tube, and necessarily in a direction contrary to the motion 
of its ciliated epithelium. 

The use of the nasal douche was first suggested by Professor 
Theodore Weber, of Halle, Germany, and is based upon a phys- 
iological fact that was first promulgated by Dr. E. H. Weber, 
of Leipsic, in 1847, This fact is, that when one side of the nasal 
cavity is entirely filled with fluid by hydrostatic pressure, while 
the patient is breathing through the mouth, the soft palate com- 
pletely shuts off the superior naso-pharyngeal space from the 
mouth, and does not permit any of the fluid to pass downward. 



NASAL DOUCHE. 383 

The fluid then passes into the opposite nasal cavity, and escapes 
through the nostril. Professor Theodore Weber suggested the 
use of a cup, to the bottom of which was attached a bit of rub- 
ber tubing, for the purpose of taking advantage of this physio- 
logical principle. The fountain syringe is now generally used 
instead of the cup. Dr. J. L. W. Thudichum brought this appa- 
ratus to the notice of the English-speaking profession, 1 and made 
it more convenient, so that in America it has acquired the name 
of Thudichum's douche. It should, however, be called Weber's 
douche. 

As early as 1869, I had found that the nasal douche was 
sometimes a troublesome and dangerous appliance, and I added 
a note to indicate this, in my translation of " Von Troltsch on 
the Ear" (second edition, page 369) ; but I was not fully con- 
vinced that it would readily cause acute aural inflammation, 
until the following case occurred in my practice. The case has 
been amplified from the first record that appeared, 2 in order to 
avoid the reiteration of explanations, that the criticisms upon 
the case in the Monatsschrift filr Ohrenheilkunde, and by Pro- 
fessor Elsberg, compelled me to make. 

Case of Otitis Media Purulenta, and Pyaemia, from the Use of the Nasal 
Douche. — On December 12, 1868, I was consulted by a clergyman, forty-nine years 
of age, in regard to a sub-acute catarrh of the middle ear, affecting both sides 
of the head. The history of the patient was as follows : Some years before, he 
was attacked with what seemed to be hay fever, or a form of coryza attacking 
certain persons during the summer. This coryza became a chronic catarrhal 
inflammation of the naso-pharyngeal space, attended by the usual synrptoms — 
a sense of stuffiness of the nostrils, frequent expectoration of glairy mucus, 
sneezing, and so forth. For the past two months the patient has been in the 
daily habit of using Weber's nasal douche, for the purpose of cleansing the 
nostrils and of introducing remedial agents into them. He had once before 
tried this means of treatment, but it had caused such unpleasant feelings in 
the ears that he was obliged to desist from employing it. A wanner solution 
was always used in the douche, and it was employed under the direction of a 
physician who was probably well aware of Dr. Thudichum's directions, and took 
all the precautions which he advises in his pamphlet. This fact is mentioned, 
because the advocates of the douche claim that it never does harm when properly 
employed. Dr. Thudichum advises that a solution of salt and water, or milk 
and water, but never pure water, should be used, as did Professor Weber some 
time before. The patient was also instructed to breathe through the month, 
and Dr. Thudichum observed that very often patients became confused, strug- 
gled, breathed through the nose, and defeated the plan. It is during this ex- 
citement, that the accident of entrance of fluid into the ear seems usually to 
occur. For about two weeks these unpleasant sensations on asing the douche 



1 On Polypus in the Nose and Ozoena. London, 18(50. Lancet, November '-24, 18o'4. 

2 Archives of Ophthalmology and Otology, Bd. I. 



SM NASAL DOUCHE. 

have been again experienced. The patient complains of being deaf, and of hav- 
ing a full sensation in both ears, almost amounting to pain. The membrana 
tympani of each side is found to be reddened. An ordinary ticking watch, 
heard by a person with normal hearing power about six feet, is only heard when 
placed in contact with the auricle of each side. A leech was applied to each 
ear, on the tragus, the Eustachian tubes were rendered pervious by means of the 
catheter and Politzer's method. In a few days the membrana tympani assumed 
a normal appearance, and the hearing was restored by means of this treatment. 
The patient then desired that an attempt should be made to relieve the trouble 
in the nasopharyngeal region. The uvula and tonsils were relaxed, the whole 
mucous membrane of the upper pharyngeal space secreted excessively, and the 
patient had contracted a habit of constantly endeaving to clear his nostrils. 
Fluids passed through the left nostril, but none through the right. The Eus- 
tachian catheter, however, passed without difficulty. The nostrils were cleansed 
by means of a nebulizer, salt and water being used in it, after which the parts 
were swabbed out with a solution of arg. nit., gr. x. ad § j. The patient improved 
under this treatment until January 28th, when he wa3 for some time exposed to 
the air of a winter's day, with the head uncovered (at the consecration of a 
bishop), when the symptoms, which had been to a certain extent relieved, re- 
turned. 

January 31st. — A gelatinous mass was found plugging up the inferior meatus 
of the right nostril, seeming to be attached to the floor of the canal. Portions 
of this were removed by torsion, at intervals of about three days, until Saturday, 
February 6th, when what seemed to be the remainder of this growth was re- 
moved. The patient left the office, saying that his nostril was much clearer, 
and went to Yonkers, a city about fifteen miles by rail from New York. There 
he again used the nasal douche, and again experienced a decidedly unpleasant 
sensation in his ears, which, however, did not amount to pain. On Sunday 
morning and evening the patient performed his clerical duties, but with a great 
sense of languor and uneasiness. On Sunday night, February 7th, at about 11 
o'clock, he was awakened by a severe pain in the mastoid region of the right ear, 
which kept him from sleep. I saw him Monday morning, at about 8 o'clock, 
and noted the following symptoms : The countenance was anxious and flushed, 
the skin hot, pulse about 96, right mastoid region red and sensitive, right mem- 
brana tympani reddened, watch only heard when pressed upon the auricle. 
The patient was asked as to the condition of the left ear ; but he said there 
was no trouble there. An examination of the tragus and mastoid process failed 
to exhibit any symptoms of inflammation in that ear. Two leeches were or- 
dered to be applied to the mastoid process, and the patient was to take aq. 
acetat. amm. At 5 p.m., the pain in the ear had entirely ceased after the appli- 
cation of the leeches. The patient was breathing hurriedly, however, his 
pulse was weak and frequent — about 96 — and he complained of pain and ten- 
derness in the abdominal region. Morph. sulph. , gr. ^, was ordered to be taken 
pro re nata, and a poultice was applied over the abdomen. Tuesday, February 
9th. — The patient took two powders of morphine, and jmssed quite a comfortable 
night. This morning he complains of pain in the forehead, but has none in any 
other part of the body. The surface of the body is dry and hot. Ordered aq. 
acetat. ammon. and nutritious diet. February 10th. — Last night the patient was 
attacked by a severe pain and swelling of the left foot, and at about 7.30 a.m. 
he had a severe chill, lasting about fifteen minutes, not followed by sweat- 



NASAL DOUCHE. 385 

ing. At this time a discharge appeared from the left ear. There has been no 
pain experienced in this part. He has not slept well, and his general appear- 
ance is bad. Countenance anxious ; breathing labored ; pulse 96. The left 
ankle and dorsal region of foot are red, greatly swollen, and tender. Left mem- 
brana tympani ulcerated and discharging freely. 

Dr. Foster Swift was called in consultation, and the following treatment 
agreed upon : The foot was wrapped in an alkaline lotion. Vichy water was 
given ad libitum, with beef-tea and wine ; morphine pro re nata. February 
11th. — Patient does not seem so well ; respiration is hurried; the intellect is 
somewhat clouded ; pulse about the same ; face of a sallow hue. The stimu- 
lants are increased, so that he now takes half an ounce of brandy in milk 
punch every four hours, day and night. Quin. sulph., gr. ij., every four hours. 
The left ear is syringed with lukewarm water, zinc, sulph. applied, and Polit- 
zer's method used to inflate the drums. The patient is so deaf that he only 
hears when spoken to near the ear. 

The patient was treated in this manner, until February 22d, the brandy punch 
being steadily increased until he was taking two ounces every four hours, with 
beef-tea, eggs, etc. His pulse was never over 100, usually about 96 ; the skin 
had a saffron hue, and patient lay in a doze, except when the pain from his foot 
kept him awake nearly the whole time. 

Dr. George A. Peters, Surgeon to the New York Hospital, was called in con- 
sultation a few days ago, in addition to Dr. Swift and myself, and to-day two 
openings were made in the foot, one near the internal, and one near the external 
malleolus. Pus was evacuated ; the dorsal region of the foot was very much 
swollen, but no fluctuation was detected. The patient's general condition is 
now better ; his countenance less anxious ; the respiration is not so hurried. 
The urine was several times carefully examined during the treatment. No ab- 
normal condition was found, beyond an acid reaction early in the course of the 
disease. The heart was also examined, and no organic changes were found. 
Several openings were made in the foot from time to time ; but the patient slowly 
improved from this time until March 16th, when he was able to sit up. The 
membrana tympani healed, and the hearing distance became about one foot on 
the right side, and four to six inches on the left. Conversation is heard with 
ease. Politzer's method has been practised every two days. Quinine and iron 
have been taken in addition to the stimulants. The foot is still swelled, but a] J 
the openings except two have healed. April 4th. — The patient has been going 
about the house for a week. Hearing power is still further improved. A little 
erysipelatous soreness of the foot occurred last night. The naso-pharyngeal 
catarrh is completely gone. April 7th. — Patient rode out to-day, and gets about 
the house, employing himself in intellectual labor. Tissues of the foot still 
swelled and rigid ; motions of the ankle-joint unimpaired. 

1884, — I am in the habit of seeing this patient quite often. He is still in 
excellent health, but a very little lame from the inflammation of the foot. 

My friend, Professor Elsberg, of this city, published a paper 1 
in which he claimed that an analysis of the eases that had been 
published, of harm to the ear from the use of the douche, showed 



1 Archives of Ophthalmology and Otology, vol. ii.. \\ 77. 
25 



386 



NASAL DOUCHE. 



that the cause was uncertain. Dr. Elsberg, has had a large ex- 
perience in treating diseases of the pharynx, and although he 
has prescribed and employed the douche in more than 1600 cases, 
he has seen none of the results that I have observed. I can only 
explain this by the presumption, that when an accident to the 
ear occurs, the patients are more apt to consult a person who is 
in the constant habit of treating aural disease, than to go on with 
the treatment of the nasal catarrh. Besides, as it is believed by 
many otologists, it is possible that the douche sets up a chronic 
inflammation of the tympanic cavity, without any acute stage, 
and thus the true cause of an insidious chronic catarrh is passed 




Fig. 87. — Vertical Section of Bones of Face (posterior half, two-thirds size. From Pro- 
fessor Darling's museum). 1, Orbit; 2, temporal fossa; 3, antrum; 4. inferior meatus; 5, 
middle meatus ; 6, superior meatus ; 7, zygomatic process ; 8, clinoid process of sphenoid 
bone ; 9, septum nasi; 10, inferior turbinated bone; 11, superior turbinated bone ; 12, alveolar 
process ; 13, ethmoid cells. 

over, and is supposed to be an advance of the naso-pharyngeal in- 
flammation. Of course, it is not believed by the author, that the 
use of the nasal douche will necessarily cause aural disease, but 
that it is a dangerous means of treatment, which should be care- 
fully watched by the practitioner. 

I append, from a paper previously published, an analysis of 
cases in which serious results have occurred. 1 Were it expe- 
dient to further extend the discussion of this subject, I could 
add several more, for I am constantly hearing of them from my 
professional friends, and seeing them in my own practice. 



Loc. cit., vol. iii., No. 1. 



NASAL DOUCHE. 



387 



Injury to the Ear from the Use of the Nasal Douche. 





Patient. 


Instructor x in use 
of douche. 


Fluid used. 


Ear disease pro- 
duced. 


Case I. 


Eev. Dr. C. 


A physician. 


A warm solu- 
tion of car- 
bolic acid. 


Acuta otitis media sup- 
purativa. Pyaemia. 
Recovery. 


II. 


Dr. Frank. 3 


Dr. Frank. 


Cold water, 
which he ad- 
vises in all 
cases. 


Acute otitis media. Re- 
covery. 


III. 


Mr. D. 


Dr. Roosa. 


Warm solution 
of salt and 
water. 


Perforation of both 
membranse tympani. 
Recovery. 


IV. 


First of Dr. C. 


A physician. 


Warm solution 


Otitis media suppura- 




I. Pardee's 3 




of salt and 


tiva. Necrosis of 




cases. 




water. 


middle ear. Perma- 
nent deafness. 


V. 


Second of Par- 
dee's 3 cases. 


A physician. 


Salt and water. 


Acute otitis media. Re- 
covery. 


Medical student. 








VI. 


A Physician. 


A physician. 


Unstated. 


Otitis media suppura- 
tiva chronica. 


VII. 


Patient at Man- 
hattan Eye and 
Ear Hospital. 


Unknown. 


Unknown. 


Otitis media acuta. Re- 
covered. 


VIII. 


Mrs. C. Dr. 
Mathewson's 
case. 


A physician. 


Warm fluids. 


Otitis media acuta. Re- 
covered. 


IX. 


Dr. Hacldey's 4 


Unknown. 


Warm salt 


Otitis media suppura- 




case. 




water. 


tiva chronica, super- 
vening on old per- 
forations. 


X. 


Dr. Piffard's 5 
case. 


Unknown. 


Warm fluids. 


Otitis media acuta. Re- 
covery. 


XI. 


Judge . 


A physician. 


Unknown. 


' ' Deafness. " Recovery. 


XII. 


Dr. Loring's G 
case. 


A physician. 


"Warm, fluid. 


Otitis media suppura- 
tiva chronica. 


XIII. 


Physician. 4 Dr. 
Mathewson's 
second case. 


A physician. 


Unstated. 


Otitis media acuta. Re- 
covery. 


XIV. 


Physician. 4 . Dr. 
Mathewson's 
third case. 


A physician. 


Unstated. 


Otitis media subacute. 


XV. 


Physician. 


A physician. 


Warm salt 


Fainting and otitis me- 






* 


water. 


dia eatarrhalis. 


XVI. 


Dr.O. D.Pome- 


Dr. Pomeroy. 


Warm salt 


Otitis media suppura- 




roy's case. 4 




water. 


tiva. 



1 The name or profession of the instructor is given, in order to meet the point made 
by the advocates of the douche, that no harm occurs when it is properly employed. 

2 Archiv fur Ohrenheilkunde, Bd. V., p. 202. 

3 The Medical Gazette, vol. vi., No. 23. Medical Record, February 1, 1870. 

4 Reported in Archives for Ophthalmology and Otology, vol. iii.. No. 0. 

6 Reported by Dr. Pardee, loc. cit. " Verbal report to writer. 

Dr. Pardee, in his paper in the Medical Oazotto, claims that the douche is an in- 
efficient, as well as dangerous instrument. Be does not think that the conformation 
of the nasal passages, allows of their being cleansed by such a flood of water as comes 
from the douche. 



388 NASAL DOUCHE. 

I am happy to say that since the publication of my warnings 
against the use of the nasal douche, on account of its danger to 
the ears, it has been very generally abandoned, and, when re- 
commended, it is with many admonitions as to care in its em- 
ployment. Since my publications on the subject, many other 
writers have urged the profession to cease to recommend it. 
Among them may be mentioned Buck, Pardee, Knapp, Beverley 
Robinson, Shaw, Rumbold, Cornwall, and others. Buck 1 makes 
the assertion, in which I fully agree, that "the introduction of 
a fluid into the nasal passages in a sufficiently large quantity 




Fig. 88. — Vertical Section of Bones of Face (anterior half, two-thirds size. From Pro- 
fessor Darling's museum). 1, Anterior cranial fossa; 2, orbit; 3, malar process; 4, alveolar 
process ; 5, inferior meatus ; 6, middle meatus ; 7, inferior turbinated bone ; 8, superior tur- 
binated bone ; 9, septum nasi ; 10, antrum ; 11, crista galli ; 12, ethmoid cells. 

to bathe the orifice of the Eustachian tube (no matter by what 
method it is introduced) is not wholly free from the danger of 
setting up an inflammation of the middle ear." 

On the other hand, such good authorities as Cassell 2 and 
Burnett 3 still recommend the douche, if used with care. 

Politzer 4 admits that, with all precautions, it sometimes hap- 
pens, "chiefly in consequence of an involuntary habit of swal- 
lowing," that fluid enters into the middle ear and causes evil 
effects. Politzer, therefore, pours medicated solutions into the 

1 Medical Record, March 24, 1877. 

2 New York Medical Journal, October, 1877, quoted from Dublin Journal Med. 
Sciences, June, 1877. 3 Text-book, p. 407. 4 Text-book, translation, p. 314. 



METHOD. 389 

nose "by means of a boat-shaped glass vessel," while the head 
is inclined backward. The patient is told to bend his head for- 
ward quickly the moment he is conscious that the fluid has 
entered his pharynx. The fluid, in consequence of the closure 
of the lower part of the pharynx, has already entered the other 
nostril, and then it will escape freely. The patient should not 
blow his nose until a quarter of an hour after the medicated 
fluid is used. This method is an awkward one. I recommend 
rather the use of Davidson's syringe as a cleanser, and that the 
medicated applications be made by a coarse spray, or by cotton 
on a cotton-holder properly curved. 

Gruber's Method. 

Gruber adopts a method of cleansing and medicating the 
naso - pharyngeal space, for which he claims superiority over 
the nasopharyngeal syringe and the nasal douche. He also 
claims that his method of treatment was promulgated a year 
before the nasal douche was introduced to the profession — that 
is, in 1863, at a meeting of the medical profession in Vienna. 
But Gruber spoke of his method only with reference to aural 
disease, while Weber's nasal douche was recommended as a 
means of treating the nares. Gruber's method consists in the 
use of a two-ounce hard-rubber aural syringe, the nozzle of 
which is well rounded off, in the following way : The syringe is 
filled with the fluid to be injected and placed in one nostril. 
The fluid is then forced with more or less vigor into the nostril, 
the other being closed with the finger, if the operator desires to 
inject the Eustachian tubes, but left open if the intention be to 
simply inject the naso-pharyngeal space. "In the force with 
which I empty the syringe, in the more or less perfect closure 
of the other nasal meatus, are found the factors which more or 
less favor the entrance of fluids through the tubes. The latter 
effect may also be increased, after the syringe is removed, by 
causing the patient to perform the Valsalvian experiment." 

Gruber believes that it is the root of the tongue, as well as 
the soft palate, that by instinctive contraction and lifting up- 
ward shuts off the superior from the inferior pharyngeal space. 
and prevents fluids injected by the nasal douche or by his 
method from passing downward. This statement is proved by 
the fact that when the soft palate is destroyed by ulceration, 
the fluid may be made to pass out of the other nostril, as well 
as if the palate were sound. 



Monatssclirift i'i'ir Ohrenheilkuiuie, Jahrgang VI., No. 4. 



390 



NASAL DOUCHE. 



Gruber deprecates much instruction to the patient as to how 
he shall breathe, or hold his palate, during the injection of the 
fluid, but he prefers to leave him to his own instincts. I am 
also convinced, that instruction to patients as to how they should 
behave while applications are made to the naso-pharyngeal 
space are useless. I inform my patients that they may act as 
they please. A fluid should be used which will do no harm if 
some of it pass into the stomach. 

Dr. Gruber fully corrobates my views that the harmful effects 
of the nasal douche, are due to the entrance of the fluid into the 
middle ear, and he shows that however proper it may be to in- 
tentionally inject fluid in small quantities into a diseased cavity 
of the tympanum, it is manifestly incorrect to force it into an 
ear that was previously healthy, with no restriction as to quan- 
tity, as is done in the use of the nasal douche. 




Fig. 89. — Nebulizer for Nostrils and Pharynx. 

"The current from the nasal douche is continuous, even when 
the cavity of the tympanum is already full : the fluid in the 
pharynx attempts more and more to enter into the middle ear, 
and when the pressure is very great, rupture of the membrana 
tympani may occur. I have often seen ecchymoses on the mem- 
brana tympani, that were caused by the nasal douche." 1 

I believe the posterior nares syringe, the Davidson's syringe, 
and the nebulizer have nearly, if not quite, supplanted the nasal 
douche. 

The solutions that may be used with benefit as gargles are, of 
course, very numerous. The gargle that I most frequently pre- 
scribe is a saturated solution of chlorate of potash, or benzoate 
of sodium, 3 j. to the pint. Where there is much granular pha- 
ryngitis, a gargle containing iodine, will probably be more effi- 
cacious. I am in the habit of advising patients suffering from 
chronic disease of the middle ear, suppurative or nonsuppura- 
tive, to use a gargle of cold water, by Von Troltsch's method, as 
long as they live. The gymnastic exercise of the muscles of the 



1 Gruber, loc. cit., N0.-8. 



NEBULIZERS— GARGLING. 391 

Eustachian tube, is by no means an unimportant means of treat- 
ment. 

Gargling is a very efficient means of cleansing the pharynx, 
if it be performed in the manner advised by Von Troltsch. The 
fluid is held in the back part of the mouth, the head being thrown 
well back, the nostrils closed by the fingers, and then the motion 
of swallowing is performed. With a little practice, the patient 
will become very proficient in this method. Those who are skep- 
tical as to the virtue of gargling, and who claim that the process 
does not cause the fluid to wash the pharynx, will be convinced 
of the contrary by the following simple experiment : Let the 
posterior wall of the pharynx be painted with the tincture of 
iodine, and then a gargle of starch- water be used in the manner 
described, and the characteristic reaction will be found in the 
ejected fluid. 

Treatment of the mouths of the Eustachian tubes, and of the 
posterior pharyngeal wall, is of great value in the treatment of 
catarrh of the middle ear. I usually use a solution of sulphate 
of zinc, of five grains to the ounce, in a nebulizer. I also employ 
nitrate of silver in weak solutions, from one to five grains to the 
ounce. I seldom use strong solutions by means of a spray, but 
when I wish to use nitrate of silver in a solution stronger than 
five grains, I find the application more safely made by means of 
a properly curved cotton-carrier. I am using strong solutions 
for simple catarrhal cases less and less, but I rely upon thorough 
and frequent cleansing by Davidson's syringe and a coarse spray. 
In the nebulizer I use a solution known as DobeH's solution very 
much. 



xn. 



^. Acid, carbol gr. vi. 

Soda Bi. Borat ) _ _ 

Soda bicarb j aa gr 

Glycerin 3 j. 

Aquae ad 3 vi. 

M. 

These applications are not very unpleasant, and they are 
certainly very efficient in diminishing secretion, and in changing 
the character of tissue. The use of the solid stick is very un- 
pleasant to the patient, and is, I think, to be avoided. 

Dr. O. D. Pomeroy, who has done much to introduce the ni- 
trate of silver treatment of the pharynx in aural disease, uses a 
peculiar instrument for making applications to the mouth of the 
tube, and for inflating the cavity of the tympanum. 1 Although 



1 Transactions of American Otoloatioal Society, 1870, 



392 FAUCIAL CATHETER. 

Dr. Pomeroy names his apparatus a faucial catheter, I am in- 
clined to think that its chief value is as a means of making appli- 
cations to the mouth of the tube, and not of inflating the middle 
ear. 

The instrument consists of a hard-rubber tube, seven and a 
half inches in length. Its breadth at its proximal extremity is 
one-fourth of an inch, but it lessens toward the beak, which is a 
little more than one-eighth of an inch in thickness. The proximal 
extremity has a lip for the adjustment of a rubber tube. At 
about an inch and a half from this is a perpendicular guide, 
placed in an opposite direction to the beak of the instrument. 
This guide serves to show the direction of the beak of the instru- 
ment when in position. The curved portion of the tube is one 
inch and three-sixteenths in length. At a line or a line and a 
half from the end of the beak, is an aperture of the calibre of a 
No. 1 Bowman's probe, for the injection of air or fluids. This 
aperture is so placed, as to cause the air or fluid to be thrown 
from the operator, or in the axis of the Eustachian tube. Air is 
injected into the mouth of the tube by simply compressing the 
air-bag, when the catheter is in position. Fluids, of which a 
drop or two are sucked up at each application into the beak of 
the instrument, are forced into the tube, in the form of a fine 
spray. 

Dr. Pomeroy thinks that the use of this instrument is ordi- 
narily simpler than the employment of Politzer's method ; but 
in this view I cannot coincide — and as a catheter, I hardly think 
it will take the place of an instrument introduced through 
the nose. The verdict of the profession has hitherto been for 
the method of Cleland, as against that of Guyot, and none of the 
faucial instruments have, as yet, reversed this judgment. The 
faucial catheter of Dr. Cutter, 1 ingenious as it is, will hardly 
supersede the catheter in ordinary use, which is, as has been 
demonstrated, an efficient instrument, and one that in ninety- 
nine cases out of a hundred is readily introduced, and with no 
"guess-work," as has been said, but with an exact knowledge 
of its position. 

Sulphate of zinc, of alum, sesquichloride of iron in weak so- 
lutions, Dobell's solution, and so on, may be used with advan- 
tage by the patient himself during the treatment of naso- 
pharyngeal inflammation. They are most efficient when used 
in one of the nebulizers that are now so largely employed in the 
treatment of the throat 2 



1 American Journal of the Medical Sciences, April, 1872. 

2 These nebulizers, to which so many different names are given, both here and 
abroad, are actually modifications of Richardson's local angesthesia apparatus. 



REMOVAL OF TONSILS. 



393 



REMOVAL OF THE TONSILS. 



It will often be necessary to remove the tonsils, or at least to 
greatly diminish their size, during the treatment of chronic 
catarrh of the middle ear. It is not prob- 
able, that the tonsils ever grow to such a 
size that they press upon the mouth of the 
Eustachian tube, as is sometimes supposed, 
but they may be so large as to seriously 
affect the breathing, the resonance of the 
voice, and the health of the pharynx and 
chest. Through the last-named influences, 
enlarged tonsils may keep up or excite a 
chronic inflammation of the middle ear. 
I invariably advise their removal, when 
they are large enough to have any of these 
injurious effects, and also, when, although 
only moderately large, they are frequently 
the seat of inflammation, and are honey- 
combed with the fistulas of former inflam- 
matory processes. For their removal, I 
usually use the tonsil bistoury here shown, 
holding the tonsil forward by the forceps. 
One assistant is generally needed, but in 
many instances, in the case of those more 
than thirteen or fourteen years of age, no 
assistant is required. The patient will 
often be willing and able, to hold his 
tongue down by means of the handle of a 
spoon or a tongue depressor. In some 
cases, I use Mackenzie's guillotine, espe- 
cially with very young children. I never 
saw any alarming hemorrhage, either in 
my own practice, or in that of my former 
preceptor, Professor Post, in whose clinic 
I have often seen this operation performed. 
The only cases, in which I would hesitate 
to perform excision of the tonsils, when it 
is required, would be in that of a person 
known or supposed to have a hemorrhagic 
diathesis. I can but think, that witli ordi- 
nary care, it would be impossible to divide 
a large artery. I apply tannic acid or 
tincture of iodine after excision. I am 
not always able to remove, with the bis- 



Fi,;. >M— Ton- 
sil Forceps. 



Fu;. 90.— 
T n s i 1 

Knife. 



394 MOUTH-BREATHING. 

toury, all of the tonsil that I desire to remove at one cut, but 
it is very unusual for the patient to decline to have a second ex- 
cision performed. 

It lias generally been observed, that persons having enlarged 
tonsils, granular pharyngitis, adenoid vegetations, or nasal ob- 
structions, breathe through the mouth. The reasons for this are 
evident. Dr. Cassels ! has made mouth-breathing the subject of 
an interesting paper entitled " Shut your Mouth and Save your 
Life." He quotes largely from Catlin, celebrated as an observer 
of the Indian tribes of this country, who denounced mouth- 
breathing in no measured terms in his work upon this subject. 
Catlin says : "If I were to endeavor to bequeath to posterity the 
most important motto which human knowledge can convey, it 
should be in three words, Shut your mouth." It is certainly of 
the highest importance, that the mouth should be kept closed in 
ordinary breathing, and if the conditions are favorable, that is 
to say, if the nostrils and pharynx are healthy, this will always 
be done. I have quoted Cassels' paper at this point, that Cat- 
lin's remarkable statements as to the hearing power of the In- 
dians of America may be noticed. Catlin claims to have visited 
two millions of individuals, living in a savage state in 150 dif- 
ferent tribes. Among this number, he found only three or four 
deaf-mutes, and not another individual who was hard of hearing 
or deaf. None of the chiefs of the tribes who were questioned 
upon this point, could remember or find an Indian who was hard 
of hearing, and Catlin further says, according to Cassels, that 
not a mouth-breather was known to exist in all these tribes. 
Dr. Ely wrote his friend, the late Lewis H. Morgan, known to 
many of my readers as a distinguished ethnologist, as to the 
correctness of Catlin's observations among the Indians, and he 
received the following reply : 

As a rule, so far as my observation has extended, the Indians are sonnd in 
hearing and in vision, both senses being more acute than with us. I have seen 
cases of sore eyes among the Western Indians and which may have been attended 
with defects in hearing. At the time, I supposed the cases due to syphilis, 
which has been a scourge upon some of the tribes. 

If you were to select a hundred Indians at random, with a hundred white men 
the same, you would, as I believe, find a larger number of the former sound- 
headed, limbed, and sound in the physical senses than of the latter. Moreover, 
on general principles this ought to be the fact. 

Yours truly, 

L. H. Morgan. 

P. S. — Catlin was a good observer. 

1 Keprint. Edinburgh: Oliver & Boyd. 1877. 



MOUTH BREATHING. 395 

I have no doubt but that Catlin was correct as to mouth- 
breathers among healthy Indians, but he overlooked the fact 
that they were nose-breathers, not from habit, but because 
they had healthy naso-pharyngeal spaces. Secure this for the 
human race, and they will all breathe with the mouth closed. In 
the writings of Catlin, and in Morgan's note, there seems to be 
an overlooking of the fact, that Indians like the Spartans, may 
have been the survival of the fittest. Delicate children, with the 
snuffles, will probably survive in civilization, when Spartan ex- 
posure, or a home in an American wigwam, would soon cut 
them off. 

A curette curved to pass behind the soft palate, is a very use- 
ful means of treating granular pharynx or adenoid growths of 
small size. The practitioner must not attach too -much faith to 
the local treatment of chronic conditions of the fauces, by nebu- 
lizers, probangs, curettes, and the like, or he will sometimes be 
grievously disappointed, and accuse himself of over-medication. 

THE TREATMENT OF THE EUSTACHIAN TUBE. 

Among the means employed in the treatment of the Eusta- 
chian tube, the use of the Eustachian catheter stands pre-emi- 
nent. It is difficult to say whether we treat the tube or the 
cavity to which it leads by the means of this instrument. We 
may often very much improve the hearing power of a patient 
by the introduction of the instrument between the lips of the 
tube, even when no air, vapor, or fluid is passed through it, 
After such a procedure it is much more easy to inflate the ear 
by Politzer's method. Some have rather hastily, as it seems to 
me, concluded that all, or the greater part of the effect produced 
by the catheter, might be had by applications to the mouth of 
the tube, and have discarded this instrument ; but I become more 
and more convinced after twenty years of pretty steady experi- 
ence in its use, that the Eustachian catheter is essential in the 
treatment of chronic non-suppurative inflammation of the mid- 
dle ear. The agents to be introduced through it are : 

Atmospheric air, 

Vapors, 

Fluids, 

Bougies, 

Electricity. 

I have placed common atmospheric air h*rst v because I regard 
it as the most important of the agents to be employed, it is. 



396 



STEAM THKOUGH EUSTACHIAN TUBE. 



however, not so efficient in chronic as in sub-acute or acute 
aural catarrh, where its effects are almost magical. In fact, it 
may be claimed, that there are no idiopathic affections for which 
relief is so immediately obtained as acute catarrhal inflamma- 
tion of the middle ear, where inflations of the tympanic cavity 
with simple air are often sufficient to cause a patient, for whom 
the world of sound is again open, to shed tears of joy. 

Among the vapors employed, the vapor of water— steam — an 
old remedy, is one of the best. 

Dr. C. I. Pardee J published a paper, in which he has care- 
fully noted the results of six cases of the most obdurate va- 







Fig. 92. — Apparatus for Steaming the Middle Ear. 

riety of non-suppurative disease of the middle ear, and in all 
of these there was marked improvement, both in the hearing 
distance and in respect to the tinnitus aurium, by the use of 
steam through the catheter. Dr. Pardee deduced from his cases 
the practical lesson, that in the treatment of the disease of the 
tympanic cavity, its condition of moisture or dryness should be 
considered, and that when dryness exists, our therapeutic efforts 
should tend to re-establish the normal secretion. 

I am in full accord with Dr. Pardee's proposition, and I do 
not therefore use the vapor of water in the strictly catarrhal 



Transactions of the American Otological Society, 1870. 



STEAM THROUGH EUSTACHIAN TUBE. 397 

cases, but in the proliferous inflammation, where adhesions ex- 
ist, with rigidity and hypertrophy of the mucous membrane. 

The apparatus required for the injection of steam into the 
cavity of the tympanum, consists of the following appliances : 

1. An apparatus for generating the vapor. 

A nickel-plated copper flask is the best for this purpose, 
although a glass flask used over a sand-bath will do very well. 
The only objection to the glass flask is, that the flame may leap 



Fig. 93.— Bottle for the Generation of the Vapor of Iodine. An ordinary air-bag is used 
for forcing the vapor into the catheter. 

beyond the level of the water in the flask, and break it, as lias 
often occurred to me. Two glass tubes are placed in the cork, 
and a very minute opening for the escape of steam. A piece of 
flexible rubber tubing is placed over each of the glass tubes. In 
the free end of one of the tubes is a nozzle adapted to the Eus- 
tachian catheter; in the other a tip adapted to an ordinary air- 
bag. 

2. A hard-rubber Eustachian catheter. A metallic instru- 



398 IODINE AND CAMPHOE. 

ment cannot be used, on account of its becoming too hot to be 
borne. Many practitioners keep the catheter in place by a 
holder ■ but I always employ my fingers for that purpose. 

The steam may be gotten up by a gas burner, as shown in 
Fig. 92, or by an alcohol lamp. If gas is to be obtained, its use 
is more convenient. The steam should be forced in by rather 
a quick pressure upon the air-bag. A slow movement, since it 
causes a longer application, is apt to burn the patient's nostrils 
or pharynx. The nozzle should be removed from the catheter 
after each puff. 

While I still think that steam employed through the catheter 
is a useful means of treating proliferous inflammation, I have 
nearly given it up, and substituted the application of the vapor 
of iodine and gum camphor, chiefly on the ground of conve- 
nience. The latter may be more easily used, and its effects 
are, I think, as useful. The practitioner may as well know, 
however, before he undertakes these cases, as to learn it by 
bitter disappointment afterward, that he will cure no cases of 
chronic proliferous inflammation of the middle ear. All he can 
hope for, is to alleviate some cases, and stay the progress of a 
few others. But this subject of prognosis will be more fully 
discussed in another place. I use iodine and camphor in pro- 
liferous disease, and fluids through the catheter in those that 
are markedly catarrhal cases. The use of iodine in the simple 
way that I now employ it, was suggested to me by Dr. F. H. 
Rankin, of Newport, formerly one of my assistant surgeons at 
the Manhattan Eye and Ear Hospital. Fig. 93 gives a clear idea 
of the apparatus necessary. The patient holds the apparatus in 
his hand, while the surgeon forces the vapor into the mouth of 
the Eustachian catheter. 

I formerly used the vapor of iodine alone, but I now, at the 
suggestion of Dr. H. P. Farnham, put about two drachms of gum 
camphor in two ounces of tincture of iodine, and force the vapor 
from this mixture through the catheter. Besides having a posi- 
tively curative value, it is very grateful and pleasant to the pa- 
tient. 

FLUIDS. 

After all the experiments to determine whether fluids forced 
into the tube through the catheter actually reach the cavity of 
the tympanum, it is, I believe, pretty conclusively settled that 
they do, and they may have a decided effect upon the lining 
membrane of this part. 

Wreden's experiments make it somewhat doubtful, whether 
a few drops of fluid, injected through the Eustachian catheter, 



FLUIDS. 399 

actually reach the cavity of the tympanum. All the experi- 
ments that have been made agree, however, in one fact, that 
where a large quantity of fluid is injected en masse, some of 
it enters the tympanum. The usual method of injecting a fluid 
into the mouth or calibre of the Eustachian tube is the follow- 
ing : the Eustachian catheter is introduced in the usual way, 
the patient having previously taken a little water in his mouth. 
A drop or two of the fluid to be injected is then placed in the 
nozzle of the catheter, and at the moment the patient swallows, 
it is forced into the tube by an air-bag. 

Dr. F. E. Weber, of Berlin, has invented an instrument for 
spraying the tube and the tympanic cavity. He calls his appa- 
ratus the "pharmaco-koniantron." It consists essentially of a 
long and flexible Eustachian catheter, which is passed into the 
tube as far as the junction of the cartilaginous with the osseous 
portion. It is perforated laterally about 1\ mm. from its beak, 
and it is introduced through an ordinary metallic catheter. The 
fluid is forced through the lateral opening in the form of spray, 
by means of an air-bag attached laterally to the tube of a small 
syringe. The fluid to be used is first driven by the syringe into 
the nozzle of the catheter, and then forced forward by the air-bag. 

As has been intimated, Dr. Wreden 1 does not believe, that 
drops of fluid injected in the manner that has been described 
through a tubal catheter, reach the cavity of the tympanum, 
but that they pass only to the osseous part of the tube. He does 
not deny that injections en masse will reach the cavity of the 
tympanum, but he thinks such injections dangerous. 

Wreden advises the use of the tympanic catheter— that is, a 
catheter that passes beyond the isthmus of the tube, as a vehicle 
for introducing drops of fluid into the middle ear. After the 
tubal catheter, through which the tympanic one is passed, is in 
position and fastened by means of a forehead band, and the 
permeability of the tube has been ascertained by the use of a 
probe 1.4 mm. in thickness, the operator drops ^.ve drops of the 
solution to be used upon a watch-crystal or other convenient 
receptacle, draws it up into the catheter and inserts the instru- 
ment as far as the tympanic orifice of the tube. The drops are 
then forced into the middle ear by the mouth. Sensations of 
fulness in the ear, and an increase of the impairment of hear- 
ing, usually occur, but they pass off in from six to twelve hours. 
In about forty-eight hours the beneficial effect should be soon. 

Wreden uses the following-named agents through the tym- 



1 Separat-abdruck nus der St. Petersburger medu-iniselien Zeitsohrift, N P., Bd 

1871. 



400 FLUIDS. 

panic catheter, and he insists that the maximal doses should not 
be exceeded, lest acute inflammation be excited. 

1. Fused caustic potash, one-quarter to one-half grain to the 
ounce of water. 

2. Liquor potassae, three to five drops to the ounce of water. 

3. Concentrated acetic acid, two to three grains to the ounce 
of water. 

4. Pure iodine, using one-eighth to one-quarter of a grain to 
the ounce of a half per cent, solution of iodide of potassium. 

5. Corrosive sublimate of mercury, one-twelfth to one-eighth 
of a grain to the ounce of water. 

6. Nitrate of silver, one-quarter to one grain to the ounce of 
water. 

7. Sulphate of copper, one-quarter to one grain to the ounce. 

8. Sulphate of zinc, one to two grains to the ounce. 

9. Iodide of potassium, two to Ave grains to the ounce. 

10. Sulphate of atropine, one-half to one grain to the drachm 
of water. 

11. Hydrate of chloral, one to two grains to the ounce of 
water. 

Wreden uses these agents through the tympanic catheter, 
chiefly in the proliferous form of inflammation of the middle 
ear. These injections are made every third or fourth day, for 
from fifteen to twenty days, and although it is not claimed that 
the results are brilliant, they are well worthy of a trial where 
all the ordinary means by a tubal catheter have failed. 

In chronic catarrhal inflammation the agents named last on 
the list are also used, but the caustic applications are only ap- 
plied to the cases of proliferous inflammation — the cases classed 
under the head of sclerosis by Troltsch. 

Kramer was perhaps the first to use the tympanic catheter 
to any great extent, and his instrument is essentially the one 
that Wreden employs. It is a hard-rubber catheter, made long 
enough to reach the tympanic orifice, and is passed into the 
tube through an ordinary tubal catheter. 

Bishop, of London, invented a nebulizer for the faucial 
mouth of the Eustachian tube ; but it was a very inconvenient 
instrument, and never came into general use. 

Dr. C. E. Hackley's instrument will be found a more efficient 
means of spraying the tube. Dr. Hackley's apparatus consists 
of an air-bag, an Eustachian catheter, with a hard-rubber nozzle 
to fit in its mouth, a piece of rubber tubing, and a hypodermic 
syringe. 1 

1 Medical Record, No. 134. 



EUSTACHIAN NEBULIZER. 401 

Ci The nozzle of the air-bag is inserted into one end of the 
rubber tube, the tip to fit in the catheter being placed in the 
other end. The hypodermic syringe is filled with the liquid to 
be employed, then its point passed through the tube and out 
through the calibre of the hard-rubber tip for the catheter, as 
shown in the cut." 

"The mouth of the Eustachian catheter B being fitted over 
the hard-rubber tip A, and held there, if sudden pressure is 
made on the air-bag, while the piston of the syringe is forced 




PiG. 94.— Hackley's Eustachian Nebulizer. 

home, the liquid will be thrown through the catheter in the 

form of spray. 

"In using this apparatus for the treatment of diseases of the 

ear, the catheter should be carefully introduced through the 

nose, and placed in position. Then, while the diagnostic tube 

is placed in the ear, the hard-rubber tip should be inserted in the 

catheter, and air alone forced through to determine whether 

the catheter be properly in position. If found to be so, the piston 

may be pressed on at the same time that air is forced through. 

During this experiment the catheter may be held in position by 

clamps for that purpose, or may be held by the fere and middle 
26 



402 politzer's method. 

fingers of the left hand, while the thumb of the same hand 
presses on the piston, the other hand being used to work the 
air-bag." 

It is well to have a small round opening made in the air-bag. 
as at C ; while the air is being forced out this may be closed by 
the finger, which then being removed, the air-bag quickly fills 
again. 

It may be said in general terms that the use of spray of 
astringent fluids to the Eustachian tube, is chiefly of value in 
those cases in which the evidences of catarrh, or increased se- 
cretion, are strongly marked, while fluids are to be employed in 
the tympanic cavity, when there is marked evidence of the pre- 
dominance of the proliferous form of disease. 

The injections of simple air, or of medicated vapors, in what 
may be called the mild cases of catarrhal inflammation, will be 
found quite as efficacious as fluids or spray. As has been al- 
ready mentioned, steam and iodine vapors are chiefly applicable 
to cases of proliferous inflammation. 

I am in the habit of employing Politzer's method of inflating 
the drum-cavity, immediately after the use of the Eustachian 
catheter, in all cases of chronic disease of the middle ear, but I 
cannot believe that it is a substitute for the catheter. It is very 
often found that no impression can be made upon the tube or 
middle ears by the use of Politzer's method alone, but after the 
catheter has been passed into the mouth of the tube, and some 
muscular spasm set up in the abductor and dilator of the open- 
ing, that this means of treatment becomes effectual at once. It 
is not well, however, to place the air-bag in the hands of the 
patient and advise him to use it. Such advice will usually be 
over-regarded, and instead of inflating the ears every other day, 
it will be done every hour perhaps. Besides, patients are often 
very unsuccessful in their attempts to drive air into the ears. 
Of course there are cases in which this system of self -treatment 
must be adopted, or none at all can be undertaken ; but physi- 
cians who treat aural disease soon learn that, if they wish to 
achieve the best results, the treatment must be carried on by 
the medical adviser himself, and not be delegated to lay au- 
thority. 

Some years since, I began to inject vapors into the ear by 
means of a simple apparatus, 1 represented on page 75. The 
apparatus consists of a hollow bulb of hard rubber, which is at- 
tached by a bit of rubber tubing to the air-bag used in Politzer's 
method. Any fluid that is readily vaporized is placed upon a 

1 American Journal of the Medical Sciences, vol. liii., p. 62. 



BOUGIES. 4Ud 

sponge contained in the bulb, and on practising inflation of the 
ear, the vapor is forced into the Eustachian tube and the cavity 
of the tympanum. The tincture of iodine and chloroform are 
the agents I chiefly employ. Dr. J. S. Prout taught me the value 
of chloroform as a means of diagnosticating closure of the tube. 
This vapor will penetrate the ear when air or iodine are not per- 
ceived, and when all attempts at inflation with air have failed, 
or, as should be said, when the patients experience no sensation 
in the ears from the use of air through the catheter, or by Po- 
litzer's method. Great caution should be used in employing the 
chloroform ; that is, but a few drops should be used, or the most 
intense pain will be caused. I have seen patients jump from 
the chair in surprise and pain, after one careful inflation, when 
only two or three drops were upon the little sponge in the bulb, 
and this, after attempts to cause a sensation in the ears with 
common air had utterly failed. The use of chloroform vapor is 
certainly a very valuable diagnostic means, although its thera- 
peutic value is very limited. The hollow bulb was recom- 
mended as an inhaler by Dr. Buttles, of this city, but it was 
intended to be used in the nostrils only. The attachment to 
Politzer's air-bag was first made by myself. 

BOUGIES. 

Bougies, for the purpose of dilating the Eustachian tube, are 
highly spoken of by some writers. Bonnaf ont and Kramer, were 
perhaps the first to use them. Guye, 1 of Amsterdam, also em- 
ployed them, and published three cases of emphysema produced 
by their use. In the first case there was emphysema along the 
neck, as far as the sternum. In three days it passed away. 
In the second there was suddenly considerable dyspnoea. The 
uvula was found to be the cause of the trouble. It was very 
much distended with air. An incision in it was made at once, 
and the patient again breathed quietly. In the third case a fold 
of mucous membrane in the fauces became so much swollen 
immediately after the use of the bougie, that breathing be- 
came difficult. Here, again, snipping the fold soon relieved the 
breathing. 

These cases probably show all the danger there is in using 
bougies. They are, however, somewhat painful. Among some 
five thousand private patients. I have recorded but very t'ew 
cases in which, after a fair trial, air could not be driven into 
the Eustachian tube by means of the catheter or Politzer's 



1 Arcliiv i'i'u- Ohronheilkunde, Bd, II., p. 0. 



404 BOUGIES. 

method. In cases where common air did not enter, the vapor 
of chloroform did. In this fact, will be found my reason for not 
resorting to the use of the bougie more frequently. Their use is 
chiefly to stimulate the mucous membrane lining the Eustachian 
tube, and thus to remove the swelling. Complete stricture of 
the tube is too rare an occurrence to be really much considered 
as an indication for the use of the bougies. I find in injections 
of vapors or fluids the stimulant thus sought without any of the 
unpleasant features of the bougie treatment, such as the produc- 
tion of emphysema, breaking of the bougie in the tube and severe 
pain. Dr. Noyes reports a case ' in which a fine whalebone olive- 
tipped bougie passed into both Eustachian tubes through the 
catheter, produced suppurative inflammation of the middle ear, 
but Dr. Noyes, as he very recently told me, still uses bougies and 
considers them indispensable for certain cases. 

In the discussion which ensued on this case, Dr. Weir said 
that he had tested the merits of the bougie practice for five 
years, and felt that in cases where obstruction of the Eustachian 
tube did not yield readily to Politzer's bag, the pump, or the 
catheter, the bougie was of very material assistance. In a large 
experience he had met with two accidents, purulent inflamma- 
tion of the middle ear, and temporary emphysema of the eyelids, 
face, and neck. These accidents occurred from neglect of certain 
rules which he now carries out. Dr. Weir uses catgut bougies 
qn which are marked the length of the catheter, the distance to 
the isthmus or narrowest part of the tube, 74 mm., then the dis- 
tance from the point to the tympanic cavity, 11 mm., and finally 
the width of the cavity, 13 mm. The bougies ranged from Nos. 
2 to 5 of the French scale. 

Dr. Weir's directions as to the employment of the bougies are 
so thorough and careful that I quote them. 

The instrument having been passed through an ordinary 
Eustachian catheter, and "once engaged in the tube is pushed 
onward as far as the isthmus, allowed to rest then a few mo- 
ments and then withdrawn, and air gently blown in through the 
catheter. If the air did not readily enter the tympanic cavity, 
all forcible attempts to force it were carefully abstained from 
and the bougie reintroduced, either then, or preferably at an- 
other sitting, and carried only to a very short distance, say one 
or two millimetres farther on, and the experiment resorted to. 
to ascertain if the tube were open." Dr. Weir has found the 
most obstructions in the first portion of the tube, though in sev- 
eral instances he had overcome total obstructions at the tym- 

1 Transactions of the American Otological Society, Third Year, p. 55. 



BOUGIES — ELECTRICITY. 405 

panic orifice. " The conical French bougies should be discarded 
as dangerous, from the tapering ends being too long; but the 
catgut bougies might be made slightly conical by rubbing them 
on emery paper." 

Within a short time, bougies have been again recommended 
by Urbantschitsch, but I have not been able to substantiate the 
opinions of those who recommend them by my own experience. 
I fear that years of careful treatment of chronic proliferous in- 
flammation in hospital and private practice, without curing any, 
have made me a little too chary about the use of troublesome 
and severe remedies for cases, for which we can expect no more 
than slight alleviation and temporary improvement. 

ELECTRICITY. 

This is an agent whose real value has been much under- 
estimated in many departments of medicine, but which I am 
inclined to believe has been overrated in the treatment of aural 
disease. The effects of electricity on the acoustic nerve will be 
fully discussed in the third part of this volume, while it is only 
necessary to say at this point, that not much is to be expected 
from the use of electricity in chronic non-suppurative inflamma- 
tion of the middle ear. Drs. Beard and Rockwell 1 think that 
"the best results are obtained in those cases passing from the 
sub-acute to the chronic stage, and that then they are brought 
about by the mechanical action of the Faradic current, on the 
adhesions within the middle ear." These are just the cases that 
are amenable to treatment by the catheter, Politzer's method, 
and applications to the pharynx. 

Before closing the subject of the employment of the Eus- 
tachian catheter in aural disease, an allusion should at least be 
made to the singular dread of the instrument, now happily dis- 
sipated, which obtained in the minds of the profession in Eng- 
land and the United States. This dread seems to have depended 
upon two cases of death from the use of the catheter which 
occurred in the practice of Dr. Turnbull, then of London, but 
who occasionally visited America, for the purpose of treating 
aural disease, until his death, which occurred a short time since. 
as I have been informed. These famous cases were reported in 
the London Lancet. In the same journal.' there is a letter from 
a correspondent accusing this Dr. Turnbull of advertising in the 

1 A Practical Treatise on the Medical and Surgical Uses of Kleetvicitv, p. 566. 

2 Vol. ii., 1839. 



406 DEATH FKOM USE OF CATHETER. 

Times in an unprofessional manner — that is, by stating that he 
could cure "any case of deafness, not arising from organic 
disease, by the use of a peculiar remedy." 

In order that the length and breadth of this matter of the 
death of patients from the use of the catheter, may be fully 
presented to the profession and not continue to be darkly hinted 
at, I quote from the Lancet 1 the account of the inquest upon 
these celebrated cases. 

On Monday evening an investigation took place at the Carpenters' Arms, 
Hoxton, before Mr. Baker, relative to the death of Mr. Win. Whitbread, aged 
sixty-six, which was supposed to have been occasioned by an operation lately 
performed on him by Dr. Turnbull, of Russell Square. It appeared that the 
deceased, who was in the enjoyment of good health up to that time, had an 
operation performed upon him on Thursday week by the above physician, which 
consisted in injecting air through the nostrils for the relief of excessive deaf- 
ness, under which he had been for some time laboring. Almost immediately 
after he was attacked with a violent swelling in the throat, and though the 
utmost attention had been paid to him, he expired on Thursday last. 

Mr. Wickharn, a medical gentleman in the neighborhood, deposed, that on 
making a post-mortem examination of the body, he found that the inflammation 
in the throat was not sufficient to have occasioned the death of the deceased ; 
death was produced by extensive inflammation of the brain, which, in his opinion, 
was occasioned by natural causes, and that neither the operation nor the inflam- 
mation of the throat had anything to do with it. 

The jury, on this evidence, returned a verdict of " Natural death by the visi- 
tation of God." 

On Friday morning, at 8 o'clock, an investigation, which occupied the greater 
portion of the day, was entered into before Mr. Wakeley, M.P., and a highly 
respectable jury of tradesmen, at the Plough Tavern, Museum Street, to prose- 
cute the inquiry into the circumstances connected with the death of Joseph 
Hall, aged eighteen, who died while undergoing an operation for the cure of 
deafness, at the house of Dr. Turnbull, Russell Square, on the morning of Sat- 
urday last. The circumstances connected with the case had created an intense 
interest, and during the proceedings the inquest-room was attended by many of 
the leading members of the medical profession. 

George Kimber merely stated that he and deceased were in the employ of 
Mr. Jackson, ornamental composition maker, of Rathbone Place. He saw him 
last alive on Saturday morning, about 7 o'clock, at which time he was get- 
ting ready to. go to Dr. Turnbull's to be operated upon for deafness, to which he 
was subject ; he was in all other respects quite well and healthy. 

Charles Spadbron, of Gravesend, deposed that he saw the deceased about 
10 o'clock on Saturday morning at Russell Square. He appeared in good 
health. There were other patients present at the time. Mr. Lyon, the gentle- 
man who assists Dr. Turnbull, was pressed to operate. The deceased filled the 
instrument himself, and discharged the air by turning the cock. (The instru- 



1 Vol. ii., p. 558. 1838. 



DEATH FROM USE OF CATHETER. 407 

ment was here produced, and the witness showed how it was filled. The bottom 
of the cylinder was held fast between the feet, and the piston worked up and 
down by the handle until the pump became filled with air.) The operation was 
repeated four times on deceased, but the tube through which the air passed was 
removed by Mr. Lyon from the right to the left nostril. On the tube being 
taken from deceased's nostril the fourth time, he fell back in the chair, appar- 
ently lifeless, and never spoke afterward. 

In answer to the coroner, the witness stated that he had had the operation 
performed on himself four times at a sitting ; it produced a swimming in the 
head, and a portion of the air appeared to escape by the mouth, and the rest 
down the throat. 

Mr. James Keid, of Bloomsbury Square, surgeon, deposed to having, by 
order of the coroner, made a post-mortem examination of the body in presence 
of Messrs. Liston, Quain, Savage, and Lyon. Mr. Eeid went into a long general 
anatomical statement, but the only points strictly bearing on the case were the 
following : That he found a thin layer of blood on the left side of the membrane, 
and globules of air under it, and in the small veins of the brain. That the left 
tympanum, or internal ear, had its lining membrane swollen, of red appear- 
ance, and there was a slight effusion of blood in it. From the known plethoric 
habit of the deceased, and from the fact of his having exerted himself at rilling 
the air-pump before he was operated upon, he should say the cause of his death 
was apoplexy. 

Mr. Savage, lecturer on anatomy at Westminster Hospital, was next exam- 
ined, and differed from the last witness, and stated that there was extravasated 
blood on both sides of the membrane, and that the tympanum of the right ear 
was affected as well as the left. He did not consider that deceased died of apo- 
plexy, but that the injection of cold air, through the Eustachian tubes, was the 
primary cause of deceased's death. 

Mr. Liston, surgeon to University College Hospital, stated that he was 
present at the post-mortem examination, at the request of the coroner, and the 
probability was, that deceased died in a continued fainting fit. He could not 
easily disconnect the forcible injection of cold air into the tympanum from the 
effect that followed it. In the region of the tympanum were a number of small 
nerves, connected with the most important one in the body, which, receiving an 
impression, would cause spasms, or other fatal affections of the heart. Xothing 
precisely satisfactory could be come to on account of the decomposed state of 
the body. 

The coroner complained that though the subject of the inquiry had died on 
Saturday morning, no notice of his death had been sent by Dr. Turnbull or Mr. 
Lyon to the summoning 'officer of the district. He wished those gentlemen to 
give some explanation of their conduct. 

Dr. Turnbull and Mr. Lyon severally entered into an explanation. 

The coroner then addressed the jury at considerable length. And in accord- 
ance with the spirit of his observations, the jury returned a verdict of '"Acci- 
dental death," with a caution to Dr. Turnbull never again to entrust the instru- 
ment of operation in unprofessional hands. — (Times.) 

There are numerous explanations for these eases ; but the 
account of the post-mortem is not exact enough to allow us to 
say which of , them are correct. The first-named patient may 



408 DEATH FROM USE OF CATHETER. 

have died from the emphysema produced by a wounding of the 
tissue by the point of the instrument. An examination of the 
tissues of the throat, immediately after the accident, would have 
determined this point ; but there is no account of such an exam- 
ination having been made. The experiments of Yoltolini ' show 
that all traces of an emphysema would pass off within ten hours 
after death, so that the post-mortem examination would give no 
information on this point. 

The surgeon who determined that death was produced by in- 
flammation of the brain, unfortunately gives no account of the 
evidences which led to the formation of this opinion. The second 
patient may have died in a fainting fit, or from emphysema. 

The air-pump, is now scarcely used in the profession as a 
means of injecting air into the Eustachian tubes, because the 
air-bag is quite as efficacious, and because it is a much simpler 
apparatus. The management of an air-press should certainly 
never be left to the patient. 

Voltolini, in the experiments to which allusion has been 
made, killed a rabbit in a few minutes by wounding the tissue 
of the pharynx, by a wire passed through a catheter, and then 
blowing forcibly into the opening. He thus produced great em- 
physema of the neck and chest. Yoltolini believes that the 
cause of death of the rabbit, was a pressure upon the larynx by 
the emphysematous tissue, and not the pressure upon the lungs. 
TurnbulFs patients may have both died from the same cause : 
but as we do not know the instrument used, or, in fact, any of 
the details, we can only surmise the real cause. 

I need hardly say that the Eustachian catheter has never 
been even suspected of being the cause of death, since the time 
of these cases, although it is in daily use by physicians in all 
parts of the civilized world. 

Before passing on to a consideration of the operative treat- 
ment for this class of aural affections, a word or two should be 
said as to the length of time a case should be treated. Inasmuch 
as we cannot hope, in many of the cases, to do more than arrest 
the progress of disease, and perhaps improve the condition, since 
we cannot dismiss them as cured — that is to say, with the hear- 
ing perfectly restored, the tinnitus aurium gone — we desire to 
know how long we shall treat the ears locally. The general 
hygienic treatment, such as the frequent employment of baths, 
of a gargle, the exercise of great care to keep the extremities 
warm, to avoid taking cold, and so on, should be kept up during 



Monatssclirift fur Ohrenlieilkunde, Jahrgang VII., No. 1. 



DUEATION OF TEEATMENT. 409 

a patient's life, and he should be told at the first consultation, 
that he has a life-long warfare to engage in, unless he desires to 
end his days with the use of an ear-trumpet. 

But we cannot keep up a local treatment of the Eustachian 
tubes and pharynx indefinitely. Those who believe that a ca- 
tarrhal pharynx and nares can be thoroughly cured in our cli- 
mate, that a disposition to colds in the head, can be effectively 
subdued by the use of the spray of nitrate of silver, or the spray 
of any other agent used by means of the most perfect apparatus, 
will continue to use these means of local treatment until the end 
is accomplished. But those who have been less successful in 
such attempts, must fix some limit to the time of treatment. If 
it be proposed to get the confidence of a patient suffering from 
chronic non-suppurative middle-ear disease, which is progres- 
sive in its character, it is proper to tell the whole truth at the 
first consultation and say that we have no hope of making him 
hear very well again. It is only a question of arresting the pro- 
gress of the disease, and perhaps of increasing the hearing 
power. To this end, about twice a year, the patient should receive 
a course of local treatment until the disease has ceased to pro- 
gress, for a period of time varying from three to eight weeks, 
while the general treatment is to be a life-long course. The 
only reason that these limits of time are fixed is, that I have sel- 
dom seen anything accomplished in less than the shorter time, 
or after the longer term has expired. Yery many patients leave 
us, at the outset, never to return. Some of them cannot leave 
their families to stay in a large city while their ears are being 
treated. This difficulty is being rapidly met. In every consid- 
erable town reputable and educated men, who have found that 
there is something more in aural practice than in syringing out 
the wax and then dropping in glycerine to restore it, are giving 
attention to otology, and the laity are beginning to reap the 
fruits of this cultivation of a hitherto barren field. 

There is another class, however, whom such advice never 
influences. One of their family has been a victim of chronic 
aural disease for a period varying from two to twenty years. 
and they have at last, at the request of the family physician, 
screwed themselves up to the courage of consulting a specialist. 
They come in town for a day's shopping, and call upon the doc- 
tor, meanwhile always being in a great hurry, and sending word 
to the consulting-room, that they have come fifty miles to see 
him. When such advice as I have delineated is given, and the 
almost bewildered physician sits down to lav etit a plan of treat- 
ment and correct the improper habits o\' life thai have induced 
and maintained the disease, he finds that he is dealing with per- 



410 DURATION OF TREATMENT. 

sons who expect magic ear-drops, vibrators, or some mysterious 
and quickly acting agent that will restore the hearing in the 
interim of rest of a New York shopping excursion. Of course, 
such patients figure in the statistical tables under the head of 
''seen but once, result unknown" although in the mind's eye 
we can set them down as going on slowly but surely to the ear- 
trumpet, and banishment from social intercourse. 

The practitioner, young or old, will do much better in such 
cases, both for the patient, his own reputation, and that of the 
profession in general, if he decline to prescribe at all for such 
persons, for it is only under favorable circumstances, that is 
to say, with intelligent patients, in easy circumstances of life, 
who are attentive to advice and punctual in attendance, that 
anything at all can be accomplished to stay the progress of a 
well-advanced catarrhal or proliferous process in the middle 
ear. 

Even then it is not always possible. Certainly those who 
have waited ten or twenty years, and have finally consulted a 
physician on account of impairment of hearing, depending upon 
chronic non-suppurative inflammation, with the idea of getting 
relief in one or two or three visits, have nothing to hope for. It 
is better to tell them so at once, lest we unwittingly emulate the 
charlatans, to whom all disease is an object of attack by medi- 
cation. Otology has suffered much, from innocent attempts to 
accomplish that which is in the nature of things, not to be ac- 
complished. A little frankness about chronic non-suppurative 
disease of the middle ear, will soon awaken the laity to the ne- 
cessity of attention to the causes of the disease, and furnish us 
all with a larger proportion of curable cases. 

I have found chronic catarrhal cases much more amenable 
to treatment than the proliferous form. Indeed, I think the 
former cases are frequently curable, but the proliferous variety 
never. In its results, in spite of good local and general care, it 
is, to my mind, very like progressive atrophy of the optic nerve 
or chronic glaucoma. 

Since the publication of the works of the modern German 
school in this country, especially that of Troltsch, there has 
been a tendency, in my opinion — I speak for myself at least — to 
refer too many cases of progressive impairment of hearing to 
catarrhal or proliferous inflammation of the middle ear, and dis- 
eases of the nerve are ignored, or their existence, except as 
secondary affections, has been even denied. 

I advise the practitioner, however, to attempt to make a dif- 
ferential diagnosis between disease of the middle ear and of the 
nerve, especially in cases of supposed chronic proliferous in- 



DIFFERENTIAL DIAGNOSIS. 411 

flammation. The means we have at hand for this purpose, will 
be fully dwelt upon when we come to the discussion of disease 
of the nerve. I will only say here, that the treatment of disease 
of the internal ear, by the local means generally employed in 
treatment of the middle ear, is harmful, since it aggravates the 
conditions by inducing congestion of the labyrinth. 



CHAPTER XV. 

THE TEEATMENT OF CHEONIC NON-SUPPUEATIVE INFLAM- 
MATION— ( Concluded). 

Operations upon and through the Membrana Tympani. — History from 1650 until our 
own Day. — Sir Astley Cooper's Cases. — Schwartze's Statistics. — Politzer's Eyelet. — 
Tenotomy of Tensor-Tympani. — Galvano-cautery. — Division of Posterior Fold. — 
Prout's Operation. — Hinton's Removal of Accumulations of Mucus — Abandonment 
of Operations by American Otologists. — Condensed Air. - Exhaustion of Air. — 
Weber-Liel and Woakes on Paretic Deafness. — Results of Treatment. 

At the time of the publication of the first editions of this book, 
operations upon the membrana tympani, the ossicles and muscles 
of the tympanum were being extensively practised by Politzer, 
Weber-Liel, Hinton, Orne Green, Pomeroy, and others, for the 
relief of chronic diseases of the middle ear. Although part of 
the treatment thus pursued was avowedly experimental, the 
hope was pretty generally felt in the profession, that operative 
procedures on and through the drum-head, might perhaps accom- 
plish very much in arresting the progress of a disease, which 
still remains incurable in a vast proportion of cases. I believe 
that after a fair trial, we are as yet obliged to say that these 
hopes have not been realized. After a trial of nearly all the 
methods of operation of which I have learned, I have aban- 
doned them, and only in exceptional instances do I ever open 
the drum-head by incisions, except in acute or sub-acute cases. 
It is not because the operations are dangerous, that I have aban- 
doned them. That I have not found. But it is because they do 
nothing to stop tinnitus aurium, or arrest progressive impairment 
of hearing in chronic non-suppurative inflammation. It may be 
asked, Why, then, consider the subject fully in a practical trea- 
tise ? To this, I answer, that it is one of great historical interest, 
for the work that has been done in this direction has been by 
the ablest of otologists, and has at least taught us much of the 
prognosis and nature of chronic non-suppurative inflammation. 
Besides, much useless experimentation on the part of younger 
observers will be avoided, if they have easy access to what has 
been already done. There is, therefore, a justification for a fall 



PEEFORATION OF MEMBRANA TYMPANI. 413 

consideration of this subject, such as I shall endeavor to give in 
this chapter. 

The reader of otological literature will be almost appalled by 
the amount of material on this subject. It begins with Chesel- 
den's experiments on the drum-heads of dogs, and ends as yet, 
with Weber's operation upon the tensor-tympani muscle, and 
Politzer s section of the posterior fold of the membrana tympani. 
From the mass of authorities I have collected a history of this 
subject. 

I am. indebted to Schwartze's brochure ' for much of the his- 
torical sketch from the time of Riolanus up to 1845, although I 
have greatly amplified his references to Sir Astley Cooper's writ- 
ings, as well as to those of other English authorities, and by no 
means, as one reviewer assumed, have I merely given a transla- 
tion of Schwartze's interesting paper. 

Johannes Riolanus (1650), of Paris, about 150 years before 
the time of Sir Astley Cooper, who is usually supposed to be the 
originator of the operation of perforation of the membrana tym- 
pani, inquired if it would not be possible to improve the hearing 
of the deaf, by destroying the membrana tympani. He was led 
to make this inquiry from the fact that he knew of a deaf per- 
son, whose hearing was restored by an accidental rupture of the 
membrana tympani, by means of an ear-spoon. 

It is well to remember that, until very recently, there were 
no exact measures taken to estimate the amount of hearing, 
and that, consequently, such phrases as "the hearing was re- 
stored," "the hearing became perfect," as they occur in ancient 
books, only mean that the hearing was improved, sometimes 
very much, sometimes very little. 

About a hundred years later (1722), T. Cheselden, surgeon to 
St. Thomas' Hospital, London, well known as the inventor of 
the operation for artificial pupil, actually operated upon dogs, 
and I quote from his work on anatomy 2 the description of his 
cases. Speaking of the membrana tympani, he says : "I found 
it once half open on a man that I dissected, who had not been 
deaf, and I have seen a man smoke a whole pipe of tobacco out 
through his ears, which must go from the mouth, through the 
Eustachian tube, and through the tympanum, yet this man 
heard perfectly well. These cases occasioned me to break the 
tympanum in both ears of a dog, and it did not destroy his hear- 
ing, but for some time he received strong sounds with great 
horror." 

1 Studien und Reobachtungen iiber die Ktinstliche Perforation dea TrommelfottB, Ar- 
chiv fur Ohrenheilkunde, Bd. 11., S, 24. 

• The Anatomy of the Human Body, p. 860* London, 1?;>2. 



414 PERFOEATION OF MEMBKANA TYMPANI. 

Cheselden then goes on to say that an anatomist named St. 
Andre assured him that "a patient of his had the tympanum 
destroyed by an ulcer, and the auditory bones came out with- 
out destroying the hearing." I have only been able to obtain 
the second edition of Cheselden's works, but Schwartze quotes^ 
from the seventh, where the author states that he obtained per- 
mission to perform this operation, that was then esteemed such 
a formidable one, upon a prisoner. If the prisoner survived the 
operation, he was to have his freedom. Unfortunately for sci- 
ence and for the criminal, the proposed subject became ill, 
so that the operation was indefinitely postponed. Sir Astley 
Cooper ' says that such an outcry was aroused by the inhuman- 
ity of the proposed operation, that Cheselden never again ob- 
tained permission to perform it. 

Dienert (1748), of Paris, in a dissertation, recommended per- 
foration of the membrana tympani for the purpose of evacuating 
blood or pus from the cavity of the tympanum. Itard says that 
Julius Busson proposed the operation six years before this. 

The first man who actually performed the operation as a 
means of benefiting the hearing, was a person named Eli (1760), 2 
who seems to have been a charlatan. 

Portal and Sabatier, two Paris surgeons, who lived at the 
same time as Eli, knew nothing of his operations. Portal pro- 
posed to puncture the membrana tympani, in the cases where it 
was greatly thickened. Sabatier, on the other hand, proposed 
to perform the operation upon a relaxed membrana tympani. 

Wilde quotes a passage 3 from Dr. Peter Degravers, of 
Edinburgh, who lived in 1788, and who styled himself Pro- 
fessor of Anatomy and Physiology, which shows that he had 
performed the operation. Degravers says : "I incised the mem- 
brana tympani of the right ear with a sharp, long, but small 
lancet. I left the patient in that state for some time, and after- 
ward observed that it had united. I incised again the mem- 
brana tympani of the right ear, but crucially, and, on removing 
some of the parts of the membrane incised, I discovered some 
of the ossicula, which I brought out." Schwartze naively re- 
marks, " There is no account of the results in this case." 

In the beginning of this century, at about the same time 

1 Philosophical Transactions, p. 152. 1800. 

2 The following paragraph is quoted by Gairal, Lincke's Sammlung, Bd. V., p. 109, 
in proof of Eli's operation: "EstLutetise homo quidam Eli dictus, qui surditatern 
curare audet, dummodo malum nona paralysi nervi septimi pan's oriater, en vero eius 
methodum tympanum exscindit et suppositum immittit. Feci experimenta quaedam, 
quae satis bene ipsi cessarunt. " 

3 Aural Surgery, English edition, p. 15. 



SIR ASTLEY COOPER'S CASES. 415 

(1800), and independently of each other, Dr. Karl Himly, then 
of Brunswick, Germany, and Sir Astley Cooper, proposed the 
operation, especially in closure of the Eustachian tube. Himly 
had demonstrated to his students, in 1797, by experiments upon 
the human cadaver and living dogs, that the operation could be 
easily and safely performed ; but he did not perform it on the 
living subject until 180G. He reports a brilliant result in one 
case only, in a person suffering from syphilitic ulcers of the 
pharynx, who had been deaf for years from closure of the Eus- 
tachian tube. 

After Sir Everard Home had published his paper on the 
functions of the membrana tympani, a paper to which allusion 
has already been made in this volume, Sir Astley Cooper pub- 
lished a careful and exact account 1 of the case of a medical 
student at St. Thomas' Hospital, in London, who had lost his 
membrana tympani, but who, nevertheless, could hear quite well. 

The student was twenty years of age, and applied to Sir 
Astley in the winter of 1797. He was attacked at ten years of 
age with suppuration in the left ear, and in about twelve months 
after with the same disease in the other ear. There was a pro- 
fuse discharge for weeks from both ears, and in the discharge 
bones, or pieces of bones, were observable. The patient was 
totally deaf for three months ; the hearing then began to return, 
and in about ten months from the last attack it was restored to 
the state in which it was when he consulted the great English 
surgeon. Sir Astley then gives an account of the. means by 
which he decided that the drum-heads were perforated. The 
patient having filled his mouth with air, he closed his nostrils 
and contracted his cheeks ; the air thus compressed was heard 
to rush through the meatus auditorius with a whistling noise, 
and the hair hanging from the temples became agitated by the 
current of air which issued from his ear. "To determine this 
with greater precision, I called for a lighted candle, which was 
applied in turn to each ear, and the flame was agitated in a sim- 
ilar manner." The examination of the case was continued in 
this thorough manner. 

The gentleman, when in company, was capable of hearing 
what was said in the usual tone of conversation, and he could 
hear with the ear in which there was no trace of a membrana 
tympani, better than with the one in which there was merely a 
circular opening. When a note was struck upon the piano, lie 
could hear it but two-thirds of the distance at which the ex- 
aminer could hear it. 



1 Philosophical Transactions, loo. oit 



416 PERFORATION OF MEMBRANA TYMPANI. 

Although this case was accessible to the profession from the 
year 1800, it is surprising to find the belief still widely prevalent 
among the laity and the profession, that the destruction of the 
membrana tympani involves almost complete loss of hearing. 
The advance in the simplicity of means of an accurate diagnosis 
in aural disease, is nowhere more distinctly seen than in a com- 
parison of Cooper's method of determining whether the mem- 
brana tympani be intact or injured, with that of the surgeon of 
the present day, who with no aid from the patient, but with the 
otoscope, is able to state just what the condition of the part is, 
and in a very brief space of time. 

This observation led the way to the operation of perforation 
of the membrana tympani 1 for the relief of impaired hearing. 
The only indication that the great English surgeon spoke of was 
closure of the Eustachian tube, which he believed arose from the 
following causes : 

1. A common cold affecting the parts contiguous to the ori- 
fices of the tube, and thereby preventing the free passage of air 
into the tympanum. 

2. Ulcers in the throat, from the scarlet fever, which in heal- 
ing frequently close the Eustachian tubes. 

3. A venereal ulcer in the fauces, by the cicatrix it produces, 
may cause a closure of the tube. 

4. An extravasation of blood in the cavity of the tympanum. 
The scientific character of Astley's observations is nowhere 

better shown than in these indications, which are exact, and in 
consideration of the state of knowledge as to the means of open- 
ing the Eustachian tube, correct. The last-named condition is 
the only one that may be said to be incorrect. The tympanic 
cavity might be full of blood without causing closure of the Eus- 
tachian tube. 

Sir Astley reports four cases : 

Case I. — A woman, thirty-six years old, who had been affected for eight 
years. The deafness arose from enlargement of the tonsil glands ; a puncture 
of the drum-head was made, and while she stayed in the consulting-room for one- 
half hour, she could hear ordinary conversation. 

Case II. — Ann D , age not stated, so deaf as not to hear words unless 

spoken close to the ear. She had been affected for six weeks. She could hear 
a watch when pressed upon her ear. After the puncture she could hear the 
watch several feet. 

Case III. — J. E , aged seventeen. The hearing had been impaired since 



1 Sir Astley's paper descriptive of his operations was read June 21, 1801. See 
Philosophical Transactions of the Royal Society of London, 1801. 



SIR ASTLEY COOPER'S CASES. 417 

birth. There was an imperfect state of the fauces, so that he could not blow his 
nose. The Eustachian tubes had no openings into his throat. Puncture of the 
rnembrana tympani produced such a confusion that he nearly fainted, but in two 
minutes he recovered, and, two months after, his hearing continued perfect. 

Case IV. — A person was sent to Sir Astley, who had received a blow upon the 
head, which had occasioned symptoms of concussion of the brain, and was attended 
with a discharge of blood from each ear. He recovered from all the effects of 
the blow but the deafness. Blood was found in the auditory canal. After clear- 
ing this away and perceiving no benefit, suspecting that a quantity of blood was 
lodged in the tympanum, in a few days he punctured the rnembrana tympani. 
Blood mingled with the wax was discharged for ten days, during which time the 
hearing was gradually restored. 

This case was undoubtedly one of fracture of the temporal 
bone through the tympanic cavity, such as have been reported 
by Buck and Rushmore. They have been fully described in the 
tenth chapter. 

In closing his paper, Sir Astley states that little pain is felt in 
the operation, and that no dangerous consequences follow. 1 The 
Valsalvian experiment was the means by which he determined 
whether the Eustachian passage was open or not, for he says 
that, when the experiment succeeds, the tube is open. Besides 
this, the patient should be able to hear a watch placed between 
the teeth or on the temporal bones. Cooper published his four 
cases of good results, and, according to Schwartze and Frank, 
he was soon inundated by deaf persons from all parts of Europe. 
He then operated on fifty more cases, but the results were either 
slight, null, or they lasted for a short time only. Cooper then 
declined to see deaf patients, on account of the fact that he was 
doing very little good, and also because his fame as a surgeon 
was suffering from his reputation as an aurist. After the lapse 
of more than seventy years, the dispassionate, scientific char- 
acter of Sir Astley Coopers writings on this subject, stands in 
striking contrast to the charlatanism of some of those who fol- 
lowed him in this operation. 

After Cooper's operations, a great interest was excited in 
France on this subject, and, according to the medical journals of 
the time, quoted by Schwartze, Riber of Bordeaux, Maunoir of 
Geneva, and others, operated, but with no permanent results. 

In Germany, also, the same interest was created. Michaelis, 
a professor in Marburg, informs his friend Hunold, of Capel, 



1 Sir William Wilde states that, within a few months of his death. Sir Astlev ex- 
hibited the greatest interest, in this subject, and left his consulting-room full of patients 
for a long time, to send for a man in Bond Street, upon whom he had operated, in 
order to exhibit him to Mr. Wilde.— Vide Dublin Journal, vol. xxv.. IS el. 
27 



418 PERFOEATIOX OF MEMBRAM TYMPANI. 

that he had operated on one case successfully. Hunold then 
proceeded to puncture every membrana tympani to which he 
could get access. Finally, Hunold records that he has had the 
brilliant result of curing or improving seventy cases out of a 
hundred. Subsequently, it was shown by others, that these 
results were not only exaggerated, but, that they were not even 
at all in accordance with truth. Of Michaelis' 63 cases, in 42 
there was no result whatever; while in 21, or one-third, there 
was greater or less improvement. But, of ' all these, in only 
one was there a permanent result six years after ; perhaps the 
benefit was permanent in three other cases. 

Schwartze says that after Hunold's marvellous accounts of 
his successful results from perforation of the membrana tym- 
pani, the operation became the fashion, and every one, who did 
not have the finest hearing, allowed the drum-heads of the ear 
to be pierced. Even the poor deaf-mutes had their drum mem- 
branes perforated. Fashions in medicine are not confined to our 
own time. 

To stem this tide of charlatanism, Karl Himly, professor in 
Gottingen, wrote a commentary upon the operation, and showed 
that it was only in exceptional cases that it was of any value. 
These exceptional cases were such as those reported by Cooper, 
for the relief of which, since there were no means of opening the 
Eustachian tube, paracentesis of the membrana tympani was a 
beneficial operation ; but the profession seem not to have studied 
Sir Astley Cooper's cases, but it was merely known that he per- 
forated the membrana tympani with benefit to the hearing. 
Himly's paper excited so much attention that the operation was 
not heard of for a long time. 

In England, as we have seen, Cooper abandoned the operation 
and otological practice. Stimulated by the opportunity for enter- 
ing an operative field, Saunders opened an aural clinic in 1804, 
but soon closed it on account of the poor results of treatment. 
He speaks of one case of perforation in which a good result was 
obtained. After him came Curtis, who talks of the operation in 
very general terms, but without furnishing cases. Buchanan 
also promised to describe his cases, but he never did ; and 
Schwartze thinks that Degravers, the Edinburgh professor, 
from whom I have quoted, and Stevenson, are not to be relied 
upon. 

In France, Itard, Boyer, and Deleau wrote upon this subject. 
Itard was wise enough to perforate a drum membrane of a deaf- 
mute whose tympanic cavity was filled with masses of tenacious 
mucus, and he succeeded in removing them after the operation 
by syringing. This was an anticipation of Mr. James Hinton's 



PERFORATION OF MEMBEAM TYMPANI. 419 

operation. In 170 other cases, there was absolutely no result. 
He calls attention to the fact that permanent suppuration may 
occur even when the operation is very carefully performed. 

Saissy (1822), of Lyons, in his work on the ear, speaks guard- 
edly of the operation, and of only one case where the result was 
entirely satisfactory. Dr. Nathan R. Smith, of Baltimore, trans- 
lated Saissy's book, and invented an instrument for perforation 
of the drum-head, which he described in the appendix to his 
translation ; but there is no account of the success of the opera- 
tion in this country. 

Schwartze gives very little credence to Deleau's account 
of his successful results. He claims to have improved eigh- 
teen out of twenty-five deaf persons and deaf-mutes, by the 
operation. 

Hendriksz, of the University of Groningen, in 1828, in an 
inaugural thesis on the subject, which Schwartze used in his 
historical sketch, states that in the institutions for the deaf and 
dumb, in Berlin, Vienna, and Groningen, this operation was fre- 
quently performed. In Groningen, 81 deaf-mutes were operated 
upon, of whom 17 received for the moment a more or less decided 
improvement. We hear nothing then of the operation for twenty 
years, until Hubert Valleroux, in 1843, wrote an essay upon the 
danger attending it. He speaks of two cases of death from it. 

Wilde, 1 in defence of the operation, when performed under 
proper indications, says that Dr. Butcher, of Dublin, reported two 
cases with a view of showing the ill-consequences resulting from 
the performance of the operation, and relates the cases of two 
young persons, a woman and a man, in both of whom it would 
appear that death ensued from puncturing the membrane. In 
the first instance, the only history of the case is that, prior to 
this period, she got a severe cold, with a swelling of the glands 
of the neck. No account is given of the cause or origin of her 
deafness, the condition of the membrana tympani, why the 
operation was performed, in what manner, by whom, or with 
what instrument. According to Wilde, all that we know is, 
that "catheterism of the Eustachian tube was performed, and 
said to fail ; hence it was agreed that the membrane of the tym- 
panum should be pierced, a small piece being drilled out of the 
membrane of the right side." No exact account of the operation 
and no names of the witnesses are given. Inflammation ensued, 
and four months after she died, when the petrous bone was found 
roughened and softened, and the membrana tympani entirely 
destroyed. This case, certainly, with such a history, can form 



Text-book, English edition, p. 897. 



420 PERFORATION OF MEMBRANA TYMPANI. 

no text for a homily against paracentesis of the drum mem- 
brane. 

The second case is equally indefinite. Wilde says all that is 
known of the case is. that he applied to a surgeon and had his 
tympanum pierced, ••'but why, or whether with a gimlet or a 
punch, a trocar or a probe, we are not informed. At first the 
hearing improved, and then relapsed. After some time head- 
symptoms set in, and the man died in six weeks/' On the jjost- 
mortem examination, the brain and its membranes were found 
in an inflamed condition, and a small abscess in the anterior 
lobe of the brain, on the same side upon which the puncture was 
made. The cause of the deafness in this case was found to be 
a small tumor, about the size of a bean, lying on the acoustic 
nerve. 

Paracentesis of the membrana tympani was certainly not in- 
dicated in this case, and the two together form no more of an 
argument against the operation, than the indefinitely reported 
cases of death from the use of the Eustachian catheter do against 
the use of that instrument. 

The treatises on diseases of the ear, of Kramer, Rau. Bonna- 
font. Toynbee. and the earlier editions of Troltsch, add very little 
to our knowledge of this subject. 

It has thus been seen, that the first indication which was set 
down by the old authors, was closure of the Eustachian tube. 

Sir Astley was incorrect in his ideas as to the closure of the 
tube being the cause of the conditions for which he opened the 
drum-head, but his operation was a proper one for those condi- 
tions, so far as we can understand his cases. For example, the 
perforation of the drum-head for the evacuation of blood was a 
proper procedure. Again, in the case of the woman who had 
been deaf for six weeks, the operation was undoubtedly of ser- 
vice, even if of only temporary value. Closure of the Eusta- 
chian tube no longer exists in the minds of the profession as an 
independent affection, except in extremely rare cases. "When 
its action is impeded, the congestion or swelling of its lining 
is always associated with similar conditions in the tympanic 
cavity. 

Since the scientific use of catheters and bougies, it is no 
longer recognized as a correct indication for perforation of the 
drum-head. In the very rare cases in which there is an imper- 
meable stricture from cicatrization, it would be a proper opera- 
tion. 

Thickening of the membrana tympani was another promi- 
nent indication of the old authors — not of Cooper, however. "We 
now know that a thickening of this membrane that is confined 



schwartze's cases. 421 

to the outer layers, may be removed by appropriate local appli- 
cations, while one that has extended to the fibrous, or mucous 
layer, or both, is nearly always accompanied by thickening of 
the whole lining membrane of the cavity of the tympanum, so 
that this indication may also be dismissed. 

A collection of blood, pus, or mucus, in the cavity of the 
tympanum, is, then, the only indication of the old writers which 
may fairly be said to be up to the present standard of knowl- 
edge. The collections are readily diagnosticated in all acute 
and sub-acute cases, and still remain good indications for per- 
foration of the membrana tympani. 

From this chaos of illy defined indications and imitative ex- 
periment, there came out one fact in proper form. That one 
fact was this : That it was pre-eminently proper to perforate the 
membrana tympani in order to remove mucus, blood, or pus, 
which could not find an exit through the Eustachian tube. Sir 
Astley Cooper's favorable cases showed this fact. Itard's deaf- 
mute was also another illustration of its truth ; but, throughout 
all the history of these cases, we do not find, until we come 
down to Saunders, 1 and later to Hermann Schwartze, of Halle, 
that one writer had been able to select this single grain of wheat 
from the chaff. Schwartze saw what had been shown by the 
cases that were published, and in his first article 2 revived the 
operation of paracentesis, but chiefly applied it to acute disease, 
where these accumulations of mucus, blood, or pus are likely to 
occur. The operation is now well established as a means of 
treatment in acute cases, and has already been described in the 
chapter on "Acute Catarrh of the Middle Ear." 

Schwartze published a few years since, 100 cases of chronic 
aural catarrh, in which he has performed a paracentesis of the 
membrana tympani. Before passing on to review the methods of 
writers who, since Schwartze's paper was published, have modi- 
fied the simple operation and enlarged its field, so as to cause it 
to play a great part, as they claim, in curing chronic cases of 
catarrhal and proliferous inflammation, I will venture to criti- 
cise Schwartze's table of results. Of his 100 cases, only '3 were 
in persons over fifty years of age. Between forty and fifty 
there were 3 persons, between thirty and forty 8. and only i; 
were over twenty. The remaining 81 were under that age, and 
46 were between one and ten years, and 35 between ten and 
twenty. In America, eases of chronic non-suppurative inflam- 
mation occurring in young persons are usually quite tractable 

1 See Introductory Chapter, p. 27. 

2 Archiv fur Ohrenbeilkmulo, Bd. II., p. 30. 



422 SCHWARTZE OX PARACENTESIS. 

without paracentesis. We are chiefly anxious to enlarge our 
therapeutic means for the cases of persons who are more than 
sixteen years of age, and especially for those who are adults in 
middle life. Again, in 34 of the cases, the disease, whatever it 
was, had not existed for a year. There were only 10 cases where 
the aural affection had lasted between five and ten years, and 
in 6 cases only, more than ten years. 1 

Schwartze, in a review of this work, seems to think that I have done him 
injustice in these remarks, as well as in the sentence where I stated that "I 
have been in the habit of treating many of the cases that he treats by paracen- 
tesis, by simpler means." He advises me to study the indications that he has 
laid down, a little more exactly. I have again gone over this subject from 
Schwartze's writings, and I am still of the opinion that many of his one hundred 
cases are not entitled to a place among cases of chronic catarrh, as generally un- 
derstood, and I also think that very many of them were curable without para- 
centesis, and that scarcely any American or English surgeon would deem this 
operation necessary for such cases. 

In saying this, I am not aware of making any rude criticism upon Schwartze's 
procedures. Certainly, I have never had any such intention. But, as a teacher 
of otology, I am bound to speak freely and frankly of any course of treatment 
publicly promulgated, even if it come from as high an authority as that of Pro- 
fessor Schwartze. 

Schwartze's cases show that valuable as is paracentesis of 
the membrana tympani, in accumulations of mucus in the tym- 
panum and in cases of catarrh of comparatively recent origin, 
we have not found in it, a remedy for old and neglected cases 
of catarrhal and proliferous inflammation. Schwartze's con- 
tributions, in other words, principally affect acute and sub- 
acute disease, or exacerbations in chronic affections. The line 
should have been a little more distinctly drawn between the 
cases of sub-acute and chronic inflammation, for which para- 
centesis was performed. In other words, Schwartze has failed, 
in my opinion, to prove by his statistics, that paracentesis is of 
any particular value in chronic cases. That it is an important 
means of treatment for acute and sub-acute cases, he proved, 
and thus revived a valuable operation. 

It was thought by many (1845) that, if a permanent opening 
could be kept in a drum-head, the great desideratum would be 
attained. Bougies were placed in an opening made with a small 
trephine, and, when it was found that this excited too much re- 
action, a gold tube, three lines long, and having a little ridge on 
both ends, was inserted, with a view of keeping up a permanent 

1 Arcliiv fill Ohrenlieilkunde, Bd. VI. , p. 195. 



politzer' s eyelet. 423 

opening. 1 This was years before Politzer introduced his eyelet. 
In 1808, Politzer had a case in which he placed an eyelet in a 
cicatrix which he had incised. Although of service in this case, 
it has proved, however, to be beneficial only in very exceptional 
cases, where, perhaps, repeated paracentesis would do quite as 
well. Several cases of accident have occurred in its use. I saw 
one case in which the opening had closed and left the foreign 
body in the cavity of the tympanum. I saw the case but once. 
Dr. Noyes 2 reported another case, where, in attempting to in- 
sert the eyelet, it was lodged, not in the membrana tympani, 
but in the cavity of the tympanum. Eighteen days after, at the 
patient's solicitation, he was placed under chloroform and the 
eyelet removed by making quite an opening in the membrana 
tympani. The suppuration from this opening ceased, and the 
opening closed in sixteen days. The hearing distance was im- 
proved, from contact with the meatus, to three and one-half 
inches while there was an opening in the membrane ; when the 
opening closed, the hearing went back to the first-named point. 
This accident of escape of the eyelet into the tympanum is thus 
one quite likely to happen, either at the time the membrane is 
pierced, or subsequently. The suppuration which occurs is more 
apt, however, to force the membrane into the tympanum than 
into the canal. 

The published experience of those who have performed this 
operation does not commend it as a successful procedure, and I 
believe that it is now very seldom performed. 

Wreden (1867), 3 of St. Petersburg, went far beyond the prop- 
ositions to make an opening in the membrana tympani, and 
excised a portion of the handle of the malleus. Inasmuch as the 
chief vascular supply of the membrana tympani was along the 
handle of the malleus, Wreden believed, and with correctness, 
that, by cutting this off, there would be less probability that the 
opening would close. He says that, when he removed two- 
thirds of the membrana tympani and the handle of the malleus, 
he never saw the opening fully heal. This operation never 
found much favor, for the reason that it proved to be dangerous 
to the hearing and even to the life of the patient. It often ex- 
cited an otitis suppurativa of so severe a form, as to destroy the 
remainder of the hearing power. It may be doubted, too. judg- 
ing from analogous cases occurring accidentally, whether even 
such an opening would not heal. The regenerative power of the 

1 Frank's Praetisrhe Anleitung, p. 810. Erlangen, 1845. 

9 Transactions of the American Otologieal Society, third your, p. 57. 
3 Monatssohrift fur OhivnheilkundY, Bd. I. 



424 INCISION WITH GALVANO-CAUTERY. 

membrana tympani is indeed marvellous. We need, however, 
spend very little time over this operation, for it has been prac- 
tically abandoned by the imitators of Wreden, if not by the dis- 
tinguished author himself. 

Voltolini, 1 following the suggestion of Erhard, made the 
incision with the galvano-cautery, in the hope that the open- 
ing made in this way would be longer in closing. He made an 
incision through the centre of the posterior section of the mem- 
brane. There was a crackling sound, as if one passed a knife 
through a tense paper. This first operation was on a patient 
who had been deaf for three years, and had suffered from fever, 
after which he became blind from cataract and deaf from un- 
known causes, or at least unstated ones. Immediately after the 
deafness appeared, which is stated to have been complete, he 
was treated by the Eustachian catheter, but without effect. 

Voltolini's first operation did not result in much if any bene- 
fit to the patient, but it proved that an opening made by the 
galvano-caustic apparatus could be kept open longer than one 
made by the knife. Voltolini improved the hearing of a patient 
in whose membrane he had made an opening with the galvano- 
cautery to such an extent, that a watch which was not heard 
before the operation, except when laid upon the auricle, was 
heard more than an inch, and ordinary conversation so well 
that the patient, who was a shop-keeper, was able to carry on 
his business. The tinnitus aurium and sensations of pressure 
in the head were also removed. 

Gruber's (1863) operation, which he calls " myringodecto- 
my," consists in forming a flap in the membrana tympani by 
means of a knife and forceps. The flap is cut off. Voltolini 
shows that this operation is both difficult and dangerous. It is 
difficult on account of the surgeon being obliged to work with 
two instruments in a narrow canal. That it is dangerous is 
shown by the histories of the cases which Gruber gives, e.g., one 
patient had fever from the 9th to the 21st of November; and 
quite severe hemorrhage during and after the operation, so that 
the auditory canal was several times filled with blood. Volto- 
lini also calls attention to the fact, that Gruber's method is but 
a modification of the old operations with perforators ; but we 
may say, that all these operations are modifications of old ideas 
and suggestions. In one of Gruber's cases the opening still ex- 
isted five months after the operation was performed. 

F. E. Weber (1808), of Berlin, 2 recommended the division of 

1 Monatssclirift fur Ohrenheilkunde, Bd. I. , p. 39. 

2 Ibid., Jahrgang II., p. 51. 



DIVISION OF TENSOR TYMPANI. 425 

the tensor tympani muscle, and the "abnormal adhesions that 
may occur in the region of this muscle." One of the chief indi- 
cations is the relief of pressure upon the labyrinth from retrac- 
tion of the tensor tympani. This muscle has its origin from the 
cartilaginous portion of the Eustachian tube, and runs along 
the edge of the bony canal, and is inserted by a well-defined 
tendon on the inner angle and inner surface of the handle of the 
malleus. 

Weber thus advanced far beyond the idea of maintaining a 
permanent opening in the membrane, and carried into effect an 
old idea of dividing abnormal adhesions that may form between 
the ossicula. 1 

Dr. Weber published an article in January, 1872, in which 
he goes very fully into the object, effect, and manner of per- 
forming his operation. It is well known that the great Vienna 
anatomist, Hyrtl, was the first to suggest this operation, but 
Weber was the first to perform it. At the time of the publica- 
tion of Weber's last article he had operated upon about fifty 
cases. 

There were two conclusions which led Weber to the per- 
formance of this operation : 1st, The fact that had been demon- 
strated that the tensor tympani muscle kept not only the mem- 
brana tympani and the ossicula with their ligaments, but also 
the labyrinth, by means of the stapes, in a state of tension, and 
that, consequently, an increased tension or rigidity of the mus- 
cle prevented the proper conduction of sound and increased the 
pressure upon the labyrinth. 2d, He also reasoned that this 
increased tension would of itself excite and maintain catarrhal 
inflammation of the tympanic cavity, especially if there was at 
the same time an affection of the tube, and that it might cause 
a hindrance to the circulation in the labyrinth, with tinnitus 
aurium, etc. In short, Dr. Weber thought it possible that many 
varieties of non-suppurative affections of the middle ear might 
depend upon excessive contraction of this muscle. 

The tenotomy is divided into four stages : 

1. The membrana tympani is perforated with the hook- 
shaped extremity of the tenotome, about 1 to 1-J mm. in front of 
the handle of the malleus, somewhat below and to one side of 
the short process. 

2. The hook-shaped knife is pushed forward into the cavity 
of the tympanum— the handle of the instrument being brought 
downward and forward — and thus it is made to grasp the ten- 
don. (Just how the operator is to know when the hook is around 

1 Loc. cit., Jubrgang IV., p, 148. 



426 DIVISION OF TENSOR TYMPANI. 

the tendon, I am unable to learn from Dr. Weber's description. 
I suppose, however, from previous familiarity with the opera- 
tion on the cadaver.) 

3. While the hook is about or over the tendon, the operator 
exerts a gentle, drawing pressure upon it, by turning the handle 
of the tenotome toward the face of the patient ; the hook is then 
turned a third upon its axis, by means of the button which acts 
upon the cog, and the tendon is cut. A distinct crackling sound 
is heard at the moment of the division of the tendon. 

4. The hook is then brought away from its position by re- 
versing the action of the button which acts on the cog, and the 
instrument is withdrawn. 

Dr. Weber at a later date gives the results of his operation 
in nine rather ponderous formulas, but they may be summed up 
in the statement that it is claimed that the operation, in most 
cases for which it is properly performed, diminishes tinnitus 
aurium, vertigo, prevents many persons from becoming abso- 
lutely deaf, and that, if a permanent result is desired, fluid must 
afterward be regularly forced into the cavity of the tympanum, 
by means of a Weber's pharmaco-koniantron. 

Weber has reported cases which confirm his view of the 
benefit from the division of the tensor tympani. It will be seen 
by reading these cases, that he follows up the operation by the 
most decided treatment of the middle ear, thus placing this 
operation where, I believe, all perforations of the membrana 
tympani should be placed, as one of the means of assisting in 
the thorough medication of the middle ear by injections of fluid 
and air. Although there is usually a temporary effect from the 
letting up of the intra-auricular pressure, it cannot be compared 
to such an operation as iridectomy for glaucoma, when the use 
of the knife ends the treatment. 

Gruber also advocated the division of the tensor tympani 
muscle, on account of the fact demonstrated by Helmholz, that 
this muscle moves the whole chain of the ossicula auditus, as 
well as the malleus, inward, a fact which causes us to believe 
that the intra-auricular pressure must be increased and morbid 
changes caused by any excessive contraction of this muscle. 
Gruber calls attention to the fact which he was the first to show, 
as he claims, that the muscle is inserted not only on the inner 
angle, but also on the anterior surface of the handle of the mal- 
leus, and he also alludes to what we have already noticed in the 
chapter on the anatomy of the middle ear, that the tensor tym- 
pani is intimately connected or united to the tensor palati mus- 
cle. This seems to indicate that the frequent affections of the 
soft palate must have some abnormal influence upon the tensor 



DIVISION OF TENSOR TYMPANI. 427 

tympani. Gruber considers the indications for a division of the 
tensor tympani to be a retraction or contraction— a shortening 
of this muscle. These indications may be known by studying 
the changes on the folds or pockets of the membrana tympani. 

"If the membrane is drawn very much inward, and the lower 
end of the malleus goes with it, while the upper retains its posi- 
tion, and thus the posterior fold becomes more prominent, we 
have an indication of the abnormal sunken position of the drum- 
head." x Gruber admits that this sinking of the drum-head may 
depend upon other causes than the retraction of the tensor tym- 
pani ; but these may be readily distinguished. The excessive 
contraction of the muscle causes the handle of the malleus to 
appear broader, and the membrana tympani to look as if twisted, 
in a state of what in surgical language is called torsion. The 
anterior ligament of the malleus, which passes from the spina 
tympanica to the neck of the malleus, also becomes more prom- 
inent, in retraction of the tendon of the tensor tympani. The 
final mark of retraction of the muscle, according to Gruber, is 
the more or less rapid reposition of the membrane in its former 
position after the air-douche has been employed. It is certainly 
very easy for us to verify these indications, as given by Gruber, 
and it is to be hoped that the operation will have a fair trial in 
the class of cases of non-suppurative disease, for which we have 
as yet done so little. 

Gruber advises that the tendon be usually divided as Weber 
recommends, in front of the handle of the malleus. The acci- 
dent that may possibly happen, if the membrane is opened pos- 
teriorly to the malleus, according to Gruber, is a perforation of 
the carotid artery, if the carotid canal be incomplete in its bony 
wall ; but this kind of an accident seems to be almost impossible, 
with any care in the management of the tenotome. As another 
argument for the anterior incision, it is stated, that the laby- 
rinth cannot be entered if the opening be made in front of the 
malleus, while the knife might possibly go through the foramen 
ovalis, if the opening be made posteriorly. Gruber uses a much 
simpler instrument than Weber's for the division of the tendon. 
It is a narrow, needle-like knife, fastened in a handle at an ob- 
tuse angle. The knife is three inches long, and has a blade 
cutting only on the anterior edge. This cutting edge is ground 
to a point, and curved to such an extent that, when the instru- 
ment is passed one-half a millimetre in front of the malleus. 
through the membrana tympani, the shaft of the needle stands 

1 Seperat-abdruek aus dor Allgemeiuea Wiener Medizinisehen Zeitung, January, 

1872. 



42S DIVISION OF TEXSOR TYMPANI. 

parallel to the long axis of the auditory canal. The point of the 
knife reaches only a little above the inner margin of the handle 
of the malleus, but does not pass far beyond the posterior seg- 
ment of the membrana tympani. 

The pain from the operation of division of the tensor tympani 
is not usually very great, and it is seldom necessary to etherize 
a patient for the purpose of performing it. Gruber performs the 
operation in cases of what he terms hypertrophic or plastic in- 
flammation of the middle ear (proliferous inflammation),, "where 
the ordinary treatment has failed to benefit the case. The head 
of the patient is held by an assistant, the drum-head well illumi- 
nated, and the tenotome is passed through the anterior segment 
of the membrane, and by turning the outer end of the knife to- 
ward the face of the patient, the point is pushed around the 
handle of the malleus to the other segment of the drum-head. 
The incision is then elongated about three millimetres, while the 
knife is held in the same position, and then withdrawn. There is 
considerable resistance in the tissue when the tendon is divided, 
and a crackling sound is heard. The hemorrhage from the 
operation is usually very slight. The air-douche, by the catheter 
or Politzer's method, should be used after the cutting is finished, 
and the ear closed lightly with cotton, while the patient should 
be kept quietly in the house and avoid taking cold. 

Those who doubt whether it is possible to divide the tendon 
without also cutting other parts, will have their doubts removed 
by performing the operation on the dead body according to the 
directions of Weber or Gruber, and then making an examination 
of the parts. 

Dr. Orne Green recommends that Gruber's operation be done 
by making the incision posterior to the handle of the malleus, 
and with a little broader knife. 1 

Hartmann uses a small knife curved on the flat and on the 
edge, for division of the tensor tympani. The point of the knife 
reaches about 1 mm. further outward than its upper edge. Hart- 
mann first makes an incision into the posterior segment of the 
membrane about 1 mm. behind the handle of the malleus, and 
learns what changes occur in the hearing distance and in the 
tinnitus aurium. The tenotome is then introduced into the tym- 
panic cavity for a distance of 3 mm. , whereby the knife is placed 
below the tendon of the tensor tympani between the handle of 
the malleus and the long cms of the incus. By slightly sinking 
its handle the sharp point of the tenotome is forced so far to- 

1 Dr. Green has some preparations made by himself in Wedl's laboratory in Vienna, 
in which the fact that the tendon is exactly and cleanly divided in his operation, is 
clearlv shown. 



DIVISION OF POSTEEIOK FOLD. 429 

ward the upper part of the tympanic cavity, that the tendon is 
obliquely divided on the withdrawal of the instrument. 1 

Lucae (1871) divided the posterior pocket or fold of the mem- 
brana tympani, in what he terms " dry catarrh of the middle 
ear" (proliferous inflammation), where there is a marked sink- 
ing inward of the handle of the malleus, and great prominence 
of the short process, and when the Eustachian tube is perme- 
able. 2 Lucae uses a bayonet-shaped needle, and the incision is 
made from below upward, in order to avoid cutting the chorda 
tympani. If this nerve be divided, it is probably not a serious 
accident, judging from cases of injury to the drum-head in 
which the chorda tympani has been injured. Of 109 cases oper- 
ated upon by this method, Lucae claims to have greatly bene- 
fited 46, and to have improved 39, while in 24 there was no 
benefit from the operation. 

A question of priority has arisen between Dr. Lucae and 
Professor Politzer, in regard to the performance of this opera- 
tion, but I will not venture to discuss this subject. 

Politzer performs the same operation, in order to render the 
membrane more movable, under the name of the incision of the 
posterior fold of the membrana tympani. The incision is a 
longitudinal one, at right angles to the long axis of the fold, 
between the short process of the malleus and the peripheric end 
of the fold. 3 

Voltolini (1870) advised the use of a probe, which is intro- 
duced daily in an opening made by the galvanic cautery, for 
some weeks after. I am not able to say whether Voltolini has 
found this method a certain means of maintaining an opening, 
but I am inclined to think not, from the fact that so little is 
heard from him on the subject. 

Dr. Prout (1872) divides adhesions between the membrana 
tympani and the promontory with a very small iridectomy-knif e. 
having a long handle. His principle of operation is, to divide 
the adhesions according to their situation. I have seen him 
perform the operation in two cases. 

In the first case 4 the membrana tympani was very much 
sunken, and an adhesion to the promontory had occurred, as 
shown by an opaque, yellow, immovable spot on the correspond- 

•Politzer: Text-book. Translation, p. 383. 

2 Seperat-abdruok aus dor Berliner Klinischen Wochenschrift, No. -t. 1872. 

3 Translation of Politzer's Lecture, by Dr. Burnett. Philadelphia Medical Times. 
vol. ii., No. 56. 

4 Myringodectomy, followed by a deoided improvement in the hearing power, in a 
case of adhesion between the membrana tympani and the promontory. Transactions 
of the Medical Society of the State of New York, 1873. 



430 prout's operation. 

ing point of the membrane. In performing the operation, Dr. 

Prout used a knife such as is here represented. 

The patient was thirty-three years of age, a teacher by occu- 
pation, and had been treated by Dr. Prout for some time 
v* previous to the operation, for advancing non-suppura- 

tive inflammation of the middle ear, but in spite of the 
use of the catheter, Politzer s method, and of the poste- 
rior nares syringe, the patient continued to grow steadily 
worse as to her hearing, and the tinnitus aurium became 
so unbearable as almost to unfit her for her daily 
duties. 

On October 3, 1871, the patient was placed under the 
influence of ether, and Dr. Prout having illuminated 
the ear by means of the otoscope upon a forehead band, 
entered the knife in front of the adhesion, and cut 
around the promontory, with which the end of the han- 
dle of the malleus was in contact. By means of " a little 
cutting, picking, and teasing, a free opening was made 
of about one and one-half lines in diameter." An at- 
tempt was made to remove the piece of membrane ad- 
herent to the promontory ; but the operator was not 
certain that he succeeded. As soon as the patient re- 
covered from the ether, she said that she heard better. 
The warm douche was used to quiet the pain, which 
was not severe, however. The hearing power for the 
voice was much improved by the operation. The patient 
was able to hear reading and conversation at thirty feet 
in front of her, while before she could on one side only, 
and then at ten feet. There was a slight purulent dis- 
charge for about a week after the operation ; but no 
very severe pain. One year after the operation the 
opening in the membrana remained of the original size ; 
j :,, the cavity of the tympanum was dry; the watch was 
heard when pressed upon the auricle — before the opera- 
tion it was not heard at all — ordinary conversation was 
readily heard at the distance of twenty feet. 
F 9r Dr. Prout thus succeeded in maintaining what may 

—Prout's fairly be called a permanent opening in the drum-head, 
and in giving great relief to the patient for a time. A 

permanent suppurative inflammation resulted from the second 

case. 

Mr. Hinton (1869) x believed that mucus dried up and became 

1 On Mucous Accumulations within the Cavity of the Tympanum. From the Guy's 
Hospital Reports, 1869. 



IIUNTT0X 01* ACCUMULATION OF MUCUS. 431 

dense in the cavity of the tympanum, and thus became a cause 
of " confirmed deafness." He therefore made an incision into the 
membrana tympani in order to remove this hardened mucus. 

Mr. Hinton's operation consists of an incision in the mem- 
brana tympani, through which fluid is injected into the cavity 
of the tympanum and Eustachian tube. The incision is made 
with a lance-shaped knife, in the inferior and posterior quadrant 
of the drum-head, and is from two to three or even more lines in 
length. The syringing is done with some force, in order to drive 
out of the cavity, into the Eustachian tube and pharynx, dried 
or inspissated mucus, the collection of which, in many cases, 
according to both pathological and clinical experience, is the 
cause of the impairment of hearing and the tinnitus. I have 
seen Mr. Hinton perform this operation, and two cases upon 
which it had been performed some time before. In both these 
cases the patients were confident that there was an improvement 
in the hearing, and a lessening of the disturbing symptoms for 
some months after the operation. 

The process of washing out the cavity of the tympanum, 
upon which Mr. Hinton lays great stress, is done by means of a 
syringe fitting hermetically into the external meatus. A solu- 
tion of bicarbonate of soda is used. The syringing, which I did 
on one occasion at Mr. Hinton's clinic at Guy's Hospital, Lon- 
don, immediately after Mr. Hinton had performed the operation, 
sometimes causes vertigo, which passes away in a few moments. 

Mr. Hinton once divided the chorda tympani nerve in per- 
forming the operation of incision of the membrane. ' k The patient 
felt a sudden shock running down the tongue, the corresponding 
side of which suffered an impairment alike of general and of 
special sensibility in its whole extent. The patient began to 
recover in two or three days." The most frequent ill effect is an 
inflammation of the external auditory canal ; when this is appre- 
hended the ear should be syringed through the Eustachian tube 
instead of the meatus. 

Mr. Hinton performed his operation in sub-acute or quite 
recent cases of accumulation of mucus in the cavity of the tym- 
panum, as well as in those of long standing, such as have formed 
the subject of discussion in the preceding chapters. 1 confess to 
a little skepticism, however, as to the fact of inspissated mucus 
being the sole cause of the impairmant of hearing in many of the 
chronic cases. The post-mortem examinations of ears, whose 
function was much impaired for a long time, thai have as yet 
been made, do not reveal this as the only lesion in many cases. 

Since the above was published. 1 have largely added fco my 
experience in operations upon the membrana tympani, and I 



432 VIEWS OF AMERICAN OTOLOGISTS. 

have also had the opportunity of studying some of the cases of 
other surgeons as if they were my own. As a result of this ex- 
perience, as I have said at the opening of this chapter, I have 
given up all operations upon the drum membrane or upon the 
tendon of the tensor tympani, in chronic non-suppurative cases, 
when there is no suspicion of retained mucus in the tympanic 
cavity. I believe that any operations yet suggested, are inade- 
quate to relieve tinnitus aurium. improve the hearing, or even 
to retard the advance of this form of disease. I read a paper ' 
expressing this opinion before the American Otological Society 
in 1881, and my views were confirmed by the members who took 
part in the discussion, by Blake, Buck, Kipp, Noyes, Burnett, 
Bartlett. Mathewson, Theobald, as representing "as well as any 
one statement could reflect the varied opinions of those who 
were interested in otological questions " (Buck). It may be said 
then, that a majority of the authorities on the treatment of aural 
disease in the United States, have up to this time, given up these 
operations in chronic non-suppurative cases, where there is no 
suspicion of fluid in the tympanic cavity. If we can yet find a 
safe means of making a permanent opening in the membrana 
tympani, I believe we should benefit quite a large class of cases, 
as yet unalleviated by any means. As Politzer 2 points out, this 
permanent opening can only be useful, " when the stapes is still 
movable, when the membrane of the fenestra rotunda is not 
thickened or calcified, and when no labyrinthine complications 
exist." I believe that we shall yet find some means of securing 
a permanent opening in the membrana tympani, for we some- 
times see cases where we find it impossible to close an opening 
made by suppuration. The application of collodion (McKeown) 
and paper disks (Blake) have been advised for relaxation of the 
drum-head. I have tried the disks, but as yet without good 
results. 

In the choice of an instrument for a simple paracentesis, it 
seems to me too much has been said. For Weber's operation, 
Gruber's knife seems to me the best, and for Prout's operation 
peculiar instruments are required, which will vary according to 
the situation of the adhesions, their size, and so on ; but for the 
ordinary paracentesis, whether we require a long or short in- 
cision, a puncture or a flap, an ordinary cataract-needle will do 
very well. Those who prefer an angular instrument will find 
Blake's knife, that which is attached to his modification of 
Wilde's polypus snare (which should be lengthened in the shank, 
however), one of the best. The use of an anaesthetic is not at 

1 Transactions, vol. ii., p. 458. - Text-book, p. 373. 



INSTRUMENTS FOR PARACENTESIS. 433 

all necessary, except where adhesions are to be divided, and the 
dissection is to be therefore prolonged. Some of the German 
authors find the membrana tympani very sensitive, even under 
chloroform ; but from what I have seen of the use of chloroform 
on the Continent, I think many of the operators are so fearful of 
the results of the anaesthetic, that they do not put their patients 
fairly to sleep. If ether be used as we use it in this country, the 
drum-head may be readily made insensible. I usually perform 
paracentesis without ether, and often in my consulting-room. I 
do not regard it as a serious or painful operation. The patient's 
head should have a good rest, and the otoscope be used on a 
forehead band, so that both hands may be free. In ordinary 
perforations for the purpose of washing out the cavity, the pos- 
terior and inferior quadrant is, perhaps, the best position for the 
incision. 

On page 287 will be found a representation of the paracen- 
tesis needle which I generally use. 

Some of the instruments formerly recommended for perforation of the mem- 
brana tympani, were probably never actually used — such as one very like a 
cork screw, and a red-hot trochar. Cooper employed a small trochar in a canula, 
the point of the trochar projecting at the most, one and a half lines. Since the 
rigid canula would be apt to hurt the membrana tympani, upon which it was 
pressed before the trochar was pushed forward, Saissy used a canula of elastic 
wood, which caused no pain. Itard punctured the membrane with a blunt 
probe. Richeraud recommended that the opening be maintained by the sub- 
sequent use of the pure nitrate of silver, in solid form ; but I have found the 
use of this caustic one of the most effectual means of closing an opening from 
an old suppurative process. ' 



THE EFFECTS OF CONDENSED AIR UPON THE HEARING POWER. 

From some peculiar, but unexplainable tendency in the hu- 
man mind, to believe in marvellous cures from means not 
usually employed by those who make the practice of medicine 
their duty in life, we occasionally hear of persons who have had 
their hearing restored by entering and remaining in chambers — 
such as the caisson used in bridge building — where the air is 
condensed, or from a stay in the so-called pneumatic cabinets. 
The exact observations of Magnus, A. H. Smith, and Green, of 
St. Louis, show that these accounts of cure of chronic nonsup- 
purative inflammation are not based on facts. On this subject, 



1 The most complete account of the instruments used or recommended for perfora- 
tion of the membrana tympani bv various authorities, is found in Beok's Krankheiten 
des Gehcrorganes, p. 45. Heidelberg and ! eipzig, 18&7. 

28 



434 CONDENSED AIR. 

Dr. Smith 1 says, "Three cases of extreme deafness came under 
my notice ; two of them in laborers, and one in the person of a 
gentleman who was advised by a physician to visit the caisson 
in the hope that he might receive benefit from the action of the 
compressed air. In all these cases the hearing was very much 
improved while in the caisson, but on returning to the open air, 
the former degree of deafness immediately reappeared." I saw 
the gentleman to whom Dr. Smith refers, and diagnosticated 
his case as one of chronic proliferous inflammation of the mid- 
dle ear. 

It might as well be claimed that deafness is cured by riding 
in a railway carriage, because the hearing is temporarily im- 
proved while the patient is there, as to assert that a cure is 
found in condensed air because persons who enter an air-cham- 
ber when the atmosphere is condensed, hear better during their 
stay. 

The only conceivable means by which a sunken drum-head 
could be improved in position and conducting power, by remain- 
ing in a chamber of condensed air, would be the rupture of the 
membrane from the force of the air, or the opening of the tubes 
by the patient's efforts to overcome the pressure. Certainly 
these ends can be accomplished in a simpler and safer way. 

Dr. Smith found, however, that sounds, such as the ticking 
of a watch, were not heard more, but less distinctly in the con- 
densed air of the caisson ; a fact which he accounts for by sup- 
posing that the great pressure on all parts of the auditory appa- 
ratus opposes a mechanical obstacle to the freedom of vibration. 
"At the same time the velocity of the waves of sound is greater, 
and hence the pitch is higher. A deep bass voice is changed to 
a treble, and the prolonged, heavy sound of a blast is so modi- 
fied as to resemble the sharp report of a pistol." 

Magnus 2 says that the conduction of sound is better in com- 
pressed air, and that we can hear the same tones better than in 
the ordinary atmosphere, provided that the membrana tympani 
is not placed in an abnormal condition — that is, an over-pressure 
allowed upon it. 



EXHAUSTION OF THE AIR IN THE AUDITORY CANAL. 

Politzer recommends the exhaustion of the air in the exter- 
nal auditory canal, by plugging the meatus with cotton-wool, 
saturated with oil, as a means of drawing out a sunken drum- 

1 The effects of high .atmospheric pressure, "before quoted in Cha}ter X. 

2 Archiv fur Ohrenheilkunde, Bd I., p. 280. 



EXHAUSTION OF THE AIR. 435 

head, when we have reason to believe that the tensor tympani 
is retracted. The patient closes the auditory canal in this man- 
ner in the evening, and removes the plug in the morning. If 
the plug be used two or three times a week, for two or three 
weeks, and no result be obtained, Politzer considers the remedy 
of no value. 

Siegle's otoscope, or pneumatic speculum, which has already 
been described, as a means of diagnosticating adhesions be- 
tween the membrana tympani and the walls of the tympanic 
cavity, has lately been much used by Dr. H. Pinkney, surgeon 
to the New York Eye and Ear Infirmary, as a means of break- 
ing up adhesions in the tympanic cavity, and of improving 
the hearing. Dr. Pinkney attaches the syringe of a stomach- 
pump to the apparatus, and exhausts the air by the use of this 
instrument. The membrane should be carefully watched during 
the process, lest too extensive ecchymosis or a rupture occur. 
I have employed the apparatus in cases of chronic proliferous 
inflammation, at Dr. Pinkney's suggestion, but with no satisfac- 
tory results. I have also cupped the membrana tympani and 
auditory canal, by placing a cup over the auricle, and exhaust- 
ing the air by means of a syringe, but with no beneficial result. 

" PARETIC DEAFNESS." 

No account of chronic non-suppurative inflammation of the 
middle ear, would be complete without a mention of the views of 
Weber-Liel, as first published in his monograph on progressive 
impairment of hearing, and in an article on affections of the 
middle ear, 1 published in a German encyclopaedia for physicians. 
The upshot of his view of the chronic affections of the middle 
ear, belonging to the proliferous form, is that a derangement of 
the tension of any of the pharyngeal, tubal, or tympanic muscles 
will bring about secondary vaso-motor changes in all the parrs 
within the tympanum. The most frequent form of such a de- 
rangement of tension is seen in a loss of power of the tensor 
palati. This induces a gradually increasing loss of hearing and 
tinnitus, sometimes accompanied by catarrh of the tympanum, 
but more likely to be associated with sclerosis. The restoration 
of the normal muscular power should be the first object of treat- 
ment. Weber-Liel, advises local electrization of the pharyngeal 
and tubal muscles, the continuous current being the most effec- 
tive. This must be combined with careful attention to the eren- 



1 Ueber das wesen und die Heilbarkeit dor houfigsten Form progressive Schwer* 
horigkeit. Berlin: Hirsckwaldj LB?<3; 



4B6 PARETIC DEAFNESS. 

eral health. Hereditary tendency to the affection makes the 
prognosis unfavorable. Lessening of the tinnitus is one of the 
best signs in the course of the treatment. A very mild astringent 
spray, introduced into the tympanum by means of the konian- 
tron, may also be used. The tendon of the tensor tympani is 
sometimes excessively contracted. If so it is to be divided. One 
symptom of the retraction of the muscle is, that the malleus is 
not only drawn in, but slightly twisted on its axis, so that its 
anterior surface is directed a little forward. Those who wish a 
fuller account will find it in the original, from which I have 
quoted, or they may study the book of Dr. Woakes. 1 

For my part, I can but think Dr. Weber-Liel's views some- 
what fanciful. His published cases, as has been suggested by 
Mr. Hinton are defective, especially as to their tests of the condi- 
tion of the acoustic nerve. Dr. Woakes has somewhat amplified 
the views of Weber-Liel, but his book is essentially a reproduc- 
tion of Weber-Liel's views. Woakes attaches great importance 
to inflammation of the gums in children in its reflex influence 
upon the ear. He seems to think that "the only obvious con- 
necting link between the regions interested (the teeth and the 
ear) is the continuity of nerve-fibre," and this he finds in the 
relations of the vaso-motor nerves. This, in my opinion, is beg- 
ging the whole question, for the direct connection between the 
buccal cavity and the Eustachian tube, is obvious enough to 
allow of the propagation of inflammation by simple continuity 
of tissue, without the intervention of the vaso-motor nerves. 

Dr. Woakes states that he had embodied his views on the 
deteriorating effect on the hearing power of certain pathological 
states of the palato- tubal muscles, in a paper which he read 
before the British Medical Association, without knowing Weber- 
Liel's paper, although "Progressive Impairment of Hearing" had 
been published for some time. Woakes' " Paretic Deafness," how- 
ever, corresponds with great exactness to Weber-Liel's ''Pro- 
gressive Impairment of Hearing." and what has been said of the 
views of the one, may be said of the other. The objections to 
referring cases of chronic proliferous inflammation to catarrh, is 
one in which I fully sympathize, but I do not think we have 
found the way out in diagnosis, by ascribing their origin to par- 
alysis of the pharyngeal, tubal, or tympanic muscles, nor in 
treatment by intra-tubal electricity, hydrobromic acid, strychnia, 
or the sesqui-carbonate of ammonia. I think it possible that 
some of Weber-Liel's cases, as well as those of Dr. Woakes, be- 
long rather to the labyrinth than to the middle ear. For my- 

1 On Deafness, Giddiness, and Noises in the Head. London, 1880. 



RESULTS OF TREATMENT. 437 

self, I think I have been in the habit in former days, of forget- 
ting that the cochlea, like the retina, may become the seat of 
chronic disease. 

RESULTS OF TREATMENT. 

In my opinion, the results of treatment of chronic non-sup- 
purative inflammation of the middle ear, will never be very grat- 
ifying. It is essentially an incurable affection. It may often be 
alleviated and sometimes arrested, but in adults never cured. It 
is pre-eminently a local disease — that is to say, a person with this 
variety of aural disease may have the best general treatment the 
world affords, and be under the most appropriate hygienic condi- 
tions ; he may live in a climate like that of Nice, Mentone, Naples, 
Aiken, or St. Augustine, and then he will not recover from his 
aural disease ; nay, more, he will continue to grow slowly but 
gradually worse if his pharynx, Eustachian tubes, and middle 
ear, are not treated by the appropriate appliances and remedies, 
and sometimes even if they are. And yet a change from a harsh 
climate^ with long winters, to a mild one, will sometimes be of 
avail in lessening the horrors of tinnitus aurium, and arresting 
the advance of disease of the middle ear. Just how much can 
be done in this way, it is difficult to estimate, for catarrhal pa- 
tients seem to grow worse in Colorado, which is so well adapted 
for many forms of phthisis. The changes of temperature in mild 
climates, are also felt very much by aural patients who have 
nasal and pharyngeal disease. One of my patients with chronic 
proliferous inflammation, has found the tinnitus aurium greatly 
relieved by a winter in the mountains of North Carolina. An- 
other with catarrhal inflammation, was happy in Florida, until 
malaria destroyed her peace. Some patients find the seashore. 
especially Newport and Narragansett, of benefit to the naso- 
pharyngeal region, ' while others cough and sneeze, and their 
"ears fill up" incessantly there. On the whole, I think the 
mountains are better for aural patients in summer. But I must 
confess that I have no exact opinions as to the influence of 
climate upon non-suppurative disease of the middle ear. The 
disease of the ear, is the last link in a long chain of improper 
conditions, and should never be considered as a primary affec- 
tion, as an entity to be subjugated or driven out by special 
means adapted to many cases. It exists in this generation, in 
larger proportion than it will in the next. For acute disease 
will then be properly considered and treated, the hygienic man- 
agement of the human body will be better understood. Just as 
chronic suppuration with its consequences, is markedly lessened 



436 PROGNOSIS. 

in our own time, as the result of a wise appreciation of •'•'ear- 
ache/' and acute catarrh, and suppuration, so will chronic ca- 
tarrh be lessened as the importance of incipient aural disease is 
more and more appreciated. If the picture of the prognosis of 
chronic affections of the ear. is a gloomy one to the young and 
enthusiastic practitioner, he must find his consolation in lessen- 
ing their number in the next decade, by a proper treatment of 
acute aural disease in this. 

There are yet. however, few medical colleges in this country 
where the otological course is complete or exact. Worse than 
this, attendance upon the lectures that are given, is generally 
not compulsory. It is only in special hospitals, and post-grad- 
uate colleges, that any adequate instruction is given, except in 
very few instances. All this must be changed, before we can 
expect a knowledge of aural pathology and therapeutics, and 
with this a decrease in the proportion of neglected and incurable 
cas--. 

If I were to sum up my conclusions after twenty years of work 
in this field. I should say that — 

1. Chronic catarrhal inflammation in young subjects, is sus- 
ceptible of relief and cure in a large proportion of cases. 

•■2. Chronic catarrhal inflammation in adults, is susceptible of 
relief and alleviation in about twenty per cent, of the cases: of 
cure in none. 

3. Chronic proliferous inflammation, remains as yet incurable 
and is not susceptible of alleviation or relief, either in the young 
or old subject, in more than five per cent, of the ca^r-, 



CHAPTER XVI. 

CHEONIC SUPPURATION OF THE MIDDLE EAE. 

Consequence of Acute Suppuration. — Otorrhcea an Improper Term. — Often confounded 
with Chronic Inflammation of the Canal. — Relative Frequency of the two Affec- 
tions. — Symptoms. — Perforations of Membrana Tympani. —Treatment. — Syringing. 
— Astringents. — Fluids. — Powders. — Electricity. — Artificial Membrana Tympani. 
— Cases. — Prognosis. 

The chapters in which acute aural catarrh and acute suppura- 
tion have been considered, have prepared us for the description 
of the disease properly known as chronic suppuration of the 
middle ear, which is a direct consequence of these affections. It 
was formerly almost universally known and described as otor- 
rhoea. But this term, simply meaning a discharge from the ear, 
and being one that does not in any proper way define the seat or 
character of the disease, should, I think, be banished from the 
nomenclature of otology. Chronic suppuration of the middle 
ear is the affection which, among the laity, is called "a running 
from the ear," and which has been so lightly regarded by the 
profession, that every year people die from its direct results, and 
under the observation of physicians, without the suspicion that 
the disease of the ear, and of the ear alone, was the cause of 
their death. In this, and in following chapters, I shall attempt to 
set forth, in a plain and simple manner, the exact nature of this 
disease, and the reasons why it should never be neglected, but 
always kept under the most careful observation and treatment. 
The name chronic suppuration of the middle ear means a 
great deal. It comprehends a large variety of disease in one of 
the important parts of the body. The term chronic suppuration 
of the middle ear, usually implies a perforation of the drum-head 
or membrana tympani. In exceedingly rare eases, there may be 
a suppuration in the tympanic cavity and mastoid cells, espe- 
cially in the latter, for weeks or even months, without the occur- 
rence of a perforation of the delicate but firm membrane that 
forms the boundary between, the middle and the external ear. 
In all but exceptional eases, however, when chronic suppuration 
of the middle ear is stated to be the diagnosis of a given case, it 
is meant that the ulceration involves the drum-head. 



440 



STATISTICS OF CHRONIC SUPPURATION 



Chronic suppuration of the middle ear is often confounded 
with that rare disease, chronic suppuration of the external audi- 
tory canal. Very many times patients have been brought to 
me. with what the attending physician supposed to be merely an 
external otitis, but which proved to be really a case of suppura- 
tion of the middle ear. with perforation of the membrana tym- 
pani. When it was demonstrated that the pus had its origin. 
not from the auditory canal, but from the middle ear. it was 
usually an easy task to convince the person affected, of the dan- 
ger of a neglect of the disease. I feel confident that this error 
as to the origin of the affection, is in many cases the cause of its 
neglect. An eczema, or a so-called seborrhoea, or even a sup- 
purative external otitis, may, perhaps, when occurring with 
young children, be left to itself or to general hygienic attention 
and tonic treatment with comparative impunity : but the best 
of such care will not usually avail to stop a formation of pus in 
the cavity of the tympanum or the mastoid cells, unless local 
treatment is also employed. 

"We might almost take it for granted, if such a practice were 
not improper in a physician who claims to observe with exact- 
ness, that any case of long-existing suppuration in. or discharge 
of pus from the ear, will be found to have its origin behind, and 
not in front of the membrana tympani. 

I have already spoken of this fact of the comparative infre- 
quency of suppurative affections of the outer ear, as compared 
with those of the middle part of the organ ; but the following 
table brings it out more strikingly than the mere assertion : 



Table showing the Relative Frequency of In flammatory Affections of the External 
and Suppuration of the Jliddle Ear. 



Institution. 


Period. 


Inflamma- 
tions of ext. 

and. canal, 
including- 
I eczema. 

1 


Suppura- 
tions of mid- 
dle ear. 


Brooklyn Eye and Ear Hospital 

Manhattan Eye and Ear Hospital 

Massaehii etts Eye and Ear Infirmary 

Glasgow Western Infirmary 

Xew York Eve and Ear Infirniarv 


15 vrs. 

14 Vrs. 

1883 

3 vrs. 5 mos. 
1882 
1882 


861 
374 
119 

43 
151 

83 


4.265 

3.270 

841 

367 
688 


Newark Charitable Eye and Ear Infirmary . . 


265 






1,631 


9,696 



All the cases under the heading "Inflammation of the Auditory Canal." were not 
necessarily suppurative ; whil^ I have heen careful to place only the suppurative cases 
in the middle ear column. 



STATISTICS OF CHRONIC SUPPURATION. 441 

It will be seen by the table, that the cases of suppuration of 
the middle ear preponderate over the cases of external otitis 
of all kinds, in a proportion exceeding that of five to one. I am 
inclined to believe that the proportion is actually even larger 
than this, and that in some cases the diagnosis was made of 
inflammation of the canal, simply because at the outset the in- 
flammation was so great as not to allow of a view of the drum- 
head, which was afterward found to be affected. If I had been 
able to exclude the non-suppurative diseases of the canal, as I 
have those of the middle ear, the preponderance of middle ear 
cases would have been much greater. 

Of 4800 cases of my own, observed in private practice, there 
were 1011 cases of suppuration of the middle ear ; of these 201 
were cases of acute suppuration, and 810 of chronic. There 
were 265 cases of inflammation of the canal, including 85 cases 
of eczema and 13 of aspergillus. 

Symptoms. — A discharge of pus is the most striking symptom 
in chronic suppuration of the middle ear. There can hardly be 
such a thing as a chronic suppuration in this part without a per- 
foration of the drum-head, through which the pus escapes. The 
term perforation, in its turn, includes a great variety of patho- 
logical conditions. 

For example, the drum-head may be entirely swept away ; 
one-half of it may be gone ; one-third of it may be gone ; only a 
small opening about as large as the head of a pin may exist ; 
two openings may exist ; so that in the very appearance of the 
drum-head we may meet the greatest difference in conditions. 

Besides, polypi may be seen through the perforation, spring- 
ing from the tympanic cavity, or there may be small growths 
or granulations hardly to be dignified by the term polypi. We 
may find the opening covered by hardened wax, or even by 
dried pus. Quite large quantities of muco-pus, pus, or of mucus, 
or of a fluid, like serum, may conceal the opening and be formed 
in a quantity sufficient to cause a constant flow into the audi- 
tory canal, or the quantity may be very small, and only to be 
detected on careful examination. In any consideration of tin 4 
diseases of the middle ear, the practitioner should remember 
that the mastoid cells, as well as the cavity of the tympanum, 
are an integral portion of this anatomical region. Hence it is 
that the lining membrane of the mastoid is usually involved in 
any inflammation of the middle ear. 

As will be seen by reference to a case recorded in a chapter 
on "The Consequences of Chronic Suppuration," pus may form, 
exist for weeks in the mastoid process, and not at all involve 



442 CHROMIC SUPPURATION — SYMPTOMS. 

the drum-head. Such cases are, however, very exceptional. A 
chronic suppuration of the middle ear, almost always involves 
an ulcerative perforation of the membrana tympani. When the 
former term is used, the latter state of things is understood to 
exist, whatever other changes of structure may have occurred. 
The discharge of pus is sometimes very profuse and constant, 
so that it streams from the ear. This is more apt to be the case 
in young children, although it occurs in adults. In such cases 
the auricle and external auditory canal become red, tender, and 
even excoriated from the irritation of the pus in which the parts 
are bathed. In other and more numerous cases, the pus lies 
only at the bottom of the canal upon the remains of the mem- 
brana tympani and in the cavity of the tympanum, enveloping 
the chain of bones, and passing into the cavities called the mas- 
toid cells. In still other cases, there is no continuous outflow of 
pus, either by day, or at night upon the pillow ; but at intervals 
there is a slight increase of the unpleasant symptoms, which 
even assume the dignity of an earache, after which a free dis- 
charge of pus from the ear occurs. On questioning such pa- 
tients in regard to the existence of a discharge from the ear, 
they will usually state that none occurs, except after an attack 
of earache, although the fact is that pus is always lying in the 
part. If we examine such an ear when the discharge is sup- 
posed to have ceased, we shall find at the bottom of the canal, 
and in the cavity of the tympanum, a hardened mass of dried 
pus covered over by cerumen or epidermis. Impacted cerumen 
is quite a frequent occurrence in the course of a chronic suppu- 
rative process in the middle ear. We shall often come to an 
erroneous conclusion as to the cause of a loss of hearing, if we 
judge of the case from the presence of hardened cerumen in the 
auditory canal, without getting the history. 

The membrana tympani presents the most varied appear- 
ance in different cases of chronic suppuration in the middle ear ; 
sometimes, it is entirely swept away, and all the ossicula with 
it. . The cavity of the tympanum is then an empty cavity open- 
ing upon the canal. Again, there is a rim remaining, with per- 
haps the incus and stapes in situ, or dislocated, but yet present, 
while the malleus is gone. In other cases the ossicula are intact 
and in position, but there are clearly cut, well-defined holes, 
from one to three in number, in the drum-head. The chromo- 
lithographs exhibit such a perforation, with the blood-vessels 
that are about to repair it, radiating toward the opening. Some- 
times one-half of the membrane is cleanly cut away. In fact, 
the appearance of the membrane is as various as the number of 
cases. The description of no one case will do for another. 



CHRONIC SUPPURATION— SYMPTOMS. 443 

Besides polypi, exostoses may exist in the canal, or even in 
the walls of the tympanic cavity ; the bone may be exposed, i.e., 
denuded of its periosteum, roughened, and in a condition of 
caries. The seventh nerve, in its passage through the aqueduct 
of Fallopius, may be destroyed by the morbid process, when the 
smirk and uncovered eye of facial paralysis are added to the dis- 
gusting detail of the ravages of disease. 

After these facts are brought to recollection, I think I am 
justified in styling the term chronic suppuration of the middle 
ear, a very comprehensive one. It is an erroneous method of 
teaching which would describe suppuration of the tympanic 
cavity and mastoid cells by the term otorrhoea, and I think that 
a discussion of the treatment of a discharge from the ear, with- 
out a comprehensive view of the important pathological condi- 
tions which may exist in this part of the body, must be in its 
very nature misleading. No discussion of the treatment of the 
formation and discharge of pus from the tympanum, will be 
profitable unless there precedes it a full understanding of the 
anatomical and pathological conditions which allow the pus to 
be formed and collected. 

If the middle ear were a simple canal or cavity, the principles 
at the basis of the treatment would, perhaps, be the same that 
they are now, but it comprises a series of anatomical parts, and 
the details in carrying out these principles are very different, 
and are much more varied than they would be were we dealing 
with a simple and easily bounded space. It is the anatomy of 
the middle ear, that makes the treatment of its diseases not an 
entirely simple matter. 

I do not think there is any one point more than another, in 
the membrana tympani, where perforations are apt to occur. 
Sir William Wilde, and Moos, quoted by Hinton, 1 affirm that 
they are most frequently situated in the anterior and lower part 
of the membrane, where the air blown through the Eustachian 
tube impinges. Hinton, has seen quite as many in the inferior 
and posterior segments, an experience which my own quite con- 
firms. I have found them in every quadrant of the drum-head. 

Perforations are sometimes so small as not to be easily recog- 
nized, unless air is forced through the Eustachian tube and made 
to pass through them. As has been stated in the preceding 
chapter, Wilde, thought that a pulsation at the bottom of the 
auditory canal was pathognomonic of perforation of the drum- 
head. Where this pulsation occurs, it is a very suspicious cir- 
cumstance ; but as has been before said in this volume, a thin 



1 Guy's Hospital Reports, Third Series, vol. xii. 



444 ALBUMINURIA FROM CHRONIC SUPPURATION. 

membrana tympani, in a state of acute catarrhal inflammation, 
will sometimes exhibit this phenomenon when the drum-head is 
intact. Mr. Hinton remarks in his excellent paper on ''Per- 
forations of the Membrana Tympani,"' from which I have just 
quoted, "This motion (pulsating) is imparted by the blood, and 
implies not necessarily an aperture, but a thin surface of fluid in 
contact with a beating vessel."' 1 The complete absence of the 
membrana tympani, especially if the mucus lining of the tym- 
panic cavity have a granular or velvety appearance, is often 
very puzzling. Such cases will sometimes require the most 
careful cleansing before we can determine how much, if any, of 
the drum-head remains. 

We need not enter into any detailed account of the condition 
of the pharynx and Eustachian tubes in the affection now under 
consideration, since this subject has been so fully dwelt upon in 
treating of the chronic non-suppurative inflammations. It may 
be sufficient to say here that we find in chronic suppuration, as 
well as in all the varieties of inflammations of the middle ear, 
except the purely proliferous forms, that the naso-pharyngeal 
region has been the usual point of origin of the disease, and 
that any successful management of the ear, will require great 
attention to the pharynx and Eustachian tube. 

The general health of a patient affected with chronic suppu- 
ration of the middle ear is usually impaired, even if none of the 
serious consequences have occurred. Such a drain upon the 
system is not tolerated with equanimity by nature. Dr. Hack- 
ley 2 has found albuminuria in a number of cases of chronic sup- 
puration of the middle ear, where there was no apparent cause 
for the disease, except the long-continued secretion of pus in the 
tympanic cavity. He is inclined to think, that such cases are 
analogous to those of the development of lardaceous kidney from 
debilitating diseases. 

The fact that a running sore is detrimental to the continu- 
ance of good general health, would scarcely need assertion, 
were it not that the author, in common with many others, has 
observed a very deeply rooted idea among the laity — an idea 
that was first inculcated, and which is even now encouraged by 
the profession — that there is no harm resulting from a chronic 
ulcerative process in the ear, when it is well out of sight. It is 
even at times gravely asserted that such a drain to the system 
is salutary, as if our Creator would not have made the human 
race with such a one if it were necessary. I have seen persons 
who allow their ears to become an offence to the nostrils of those 



1 Loc. cit , p. 630. ' Verbal communication at New York Oplitlialmological Society. 



SUPPOSED DANGER FROM STOPPING THE DISCHARGE. 445 

about them, because they have been advised by their physician 
that it was not best to "meddle with the ear." If my reader 
feels that I have said too much on this subject, in the different 
parts of this volume, I beg that he will ask himself how many 
cases of death he has known as the result of a suppurative pro- 
cess in the ear, consult his fellow practitioners on the same 
point, and finally investigate the statistical tables of deaf and 
dumb asylums. In the answers to these queries will be found 
a complete justification of my earnestness on this point. The 
anatomy of the middle ear, showing, as it does, the relations of 
this small portion of the organism to the most important parts 
of the system, to the great arterial and venous vessels, to the 
nervous system, to the organs of respiration, is also of itself a 
sufficient proof of the necessary importance of a long-continued 
suppuration in this part. 

There still exists, however, even in the minds of some phy- 
sicians, a prejudice against the stoppage of a purulent discharge 
from the ear. In the laity this prejudice is widely spread, and 
is chiefly dependent upon the erroneous teachings of the older 
French writers, Du Verney and Itard. As Wilde shows, m his 
classic article upon this disease in his text-book, "Because it 
was observed that on the supervention of cerebral disease, dis- 
charges from the auditory canal have lessened, practitioners 
mistaking the effect for the cause, have been led to believe that 
the sudden 'drying up' produced a metastasis to the brain, a 
notion as crude as it is unsupported." There is, I believe, no 
pathological experience on record which can sustain the quite 
common assertion that it is dangerous to stop a discharge from 
the ear. There are some cases on record — of which there are. 
alas ! many more than were ever recorded — where disease of 
the brain has occurred from the extension of a neglected sup- 
puration to the cerebral membranes and substance, and the dis- 
charge from the ear has nearly ceased ; but these certainly form 
no argument against the arrest of an ulcerative process before 
any parts beyond the cavity of the tympanum are involved. 

He who believes that we can easily cause a discharge oi' pus 
to cease, after caries of the temporal bone lias occurred, will 
find many cases which will cause him to doubt the efficacy of 
his therapeutics. As well might we refuse to heal an ulcerated 
hip-joint, as to neglect to cheek a discharge from a diseased 
membrana tympani or lining membrane oi' the tympanic cavity. 

It is doubtless true, judging from the histories o\' eases and 
the inspection of the membrana tympani. in which cicatrices 
occur, that many cases of chronic suppuration are cured with 
very slight treatment, or with none at all. The fact remains. 



446 HEARING POWER WITH PERFORATION. 

however, that many of the neglected cases do not so recover, 
and after a purulent discharge from the ear has once set in, 
"we can never tell" to quote again the words of Wilde, which 
should be impressed upon the attention of every practitioner of 
medicine, "how, when, or tvhere it will end, or what it may. 
lead to." 1 

A careful treatment is usually required to check the dis- 
charge and treat the ulcerated membrana tympani, and restore 
the hearing power. Even with the most careful and skilful 
treatment, we cannot always succeed in all of these things. In 
some rare cases we do not succeed in any of them ; but the pa- 
tient, in spite of our best efforts, will go on to his doom. 

The degree of the impairment of hearing, in cases of chronic 
aural suppuration, is very variable. It depends, of course, upon 
many factors ; for example, the condition of the Eustachian 
tube, and the integrity of the structure in the cavity of the tym- 
panum. The hearing power by no means depends upon the 
presence or absence of the membrana tympani. The chief func- 
tion of this membrane is probably to protect the tympanic cav- 
ity, and not merely to transmit the vibrations of the atmosphere, 
which when conveyed to the acoustic nerve we call sound. I 
know some persons who have large perforations in each mem- 
brana tympani, and who yet hear well enough for all the ordi- 
nary purposes of life, although not with perfection. One notable 
instance of this kind is that of a busy physician of my acquaint- 
ance. As has been already said in the last chapter, Sir Astley 
Cooper, in a paper published in the " Transactions of the Royal 
Society," in 1800, 2 showed that there could be very good hearing 
powers with a perforate membrana tympani ; and yet I very 
often hear the question asked, as well by physicians as by lay- 
men, if anything can be done when there is a hole in this mem- 
brane ; and it is also often stoutly asserted that when this mem- 
brane is once gone, the hearing is irrevocably lost. This false 
idea continues to prevail, not only in spite of scientific demon- 
stration of more than seventy years ago, but also in the face of 
clinical facts that are every day within the reach of each atten- 
tive physician. Truly, a lie will travel around the world, while 
truth is putting on its boots. 

The parts which form the middle ear make up a cavity which 
has perhaps as many, if not more, important anatomical re- 
lations than any one of similar size in the human body. The 
cavity of the tympanum is covered above by a thin, rarefied 
bony plate, which is in direct communication with the cerebral 



Text-book, p. 407. 2 Philosophical Transactions, Part I. 1800. 



REMOVAL OF PUS FROM TYMPANUM. 447 

meninges ; the floor is close to the great jugular. Its internal 
wall is the labyrinth wall, with its two fenestra?, covered only 
by thin membrane and opening into the ramifications of the 
acoustic nerve and the fluid, which is continuous with that of 
the sub-arachnoid, space ; while externally we have a membrane 
of about the thickness of letter-paper. 

Treatment. — The proper treatment of a chronic suppuration 
in such a space should be a matter of the greatest solicitude. It 
involves not alone the hearing power, but also the life of the 
patient. There is one pre-requisite to the successful treatment 
of this affection, and that is, a complete removal of all the mor- 
bid material that has formed in the middle ear. This is simply 
another way of stating that the parts must be thoroughly 
cleansed. 

As we have seen in the discussion of the various affections 
of the middle ear, their starting-point is usually in the fauces or 
pharynx. But the ulcerative process which has been set up in 
the tympanic cavity has broken through the membrana tym- 
pani, and the result shows itself in the external auditory canal. 
The problem to be solved is, how may we stop the ulcerative 
process, heal the membrana tympani, and restore the hearing- 
power, which has been impaired by the inflammatory process in 
the sound-conducting apparatus ? In many cases, however, we 
may be well satisfied if two of these requirements be fully ful- 
filled, while the hearing power is improved. A radical cure of 
a suppurative process in the middle ear, of long standing, is. 
from the very nature of things, sometimes impossible. 

The old method of treating such a suppuration was to advise 
the patient to syringe the ears with soap and water, put a blister 
on the mastoid process, and at the same time the physician got 
the system to rights by using alteratives, laxatives, and purga- 
tives. The general principle of treatment thus held in view 
was correct, but in the matter of the local treatment, which is 
of far more importance than the constitutional, altogether too 
much was left to the supposed knowledge and skill of the pa- 
tient or his attendant. 

Perhaps not more than one layman in a hundred can. with- 
out instruction, thoroughly cleanse an ear by syringing. It is 
generally thought that any person can syringe an ear, when the 
facts are that no patient can properly cleanse his own ear, and 
almost everyone requires instruction before he can even syringe 
the ear of another. In one of the preceding chapters of this book 
(see page 1 ;>:>), the proper method o( syringing has been care- 
fully described, so that we need not dwell upon the subject again. 



448 OBJECTIONS TO THE SYRINGE. 

Objections have been made to the use of the syringe. One 
authority, for whom I have a great respect, says, in referring to 
the cleansing of the ear from pus, and in italics, too, "The syr- 
inge, as a rule, is not to be used." J When differences of opinion 
like this as to modes of treatment arise, there is not much to be 
said except to show that one recognizes his own standpoint, and 
the difficulties of it, and gives good heed to the contrary one. I 
think I am not ignorant of the abuse of syringing, or of the fact 
that much that is called cleansing the ear by syringing has no 
right to such a name. I am also well aware of the ill effects in 
isolated cases from syringing. I once reported 2 a case in which 
a gentleman who consulted me suffered so seriously from syn- 
cope, after a very gentle syringing of the ear, that for some 
moments it was thought by myself and others, that he would 
certainly die. This patient, however, would probably suffer in 
the same way from any surgical procedure. After his recovery 
he told me that he had once fainted in the same alarming way 
on calling upon a surgeon who proposed to make some kind of 
an examination. Faintness, vertigo, and nausea are also some- 
times produced even by gentle syringing of the ear. Yet, if the 
proper method is practised, and the proper care as to gentleness 
be taken, it is not one case in a hundred in which any unpleasant 
symptoms will occur. Simple a procedure as it is, the proper 
method must first be learned. The water should be warmed ; it 
should be injected into the concha before it is allowed to pass 
into the auditory canal — in short, until you know your patient, 
you should always proceed very slowly and gently with the syr- 
inge, especially in the removal of pus. 

But, in spite of all these drawbacks, none of which I would 
underrate, I believe, as an outcome of twenty years' active ex- 
perience in aural disease, that it remains the best means, on the 
whole, in by far the largest number of cases of cleansing the ear. 
I cannot think that the use of warm water to the ear thoroughly 
and often is any more dangerous, but, on the contrary, of the 
same amount of good as the use of the same agent in the same 
way in cleansing fistulous ulcers, open cavities, and other parts 
of the body which may from time to time become filled with 
pus, I see no argument in the reasoning that, because warm 
water may soften the tissue, its use should be avoided for the 
purpose of cleansing a cavity which requires it. The best syr- 
inge which I have ever seen is one to be procured in Paris of 
Liier, which has not come into general use, which we are using 

1 Diseases of the Ear, by A. H. Buck, p. 232. 
- Archives of Otology, vol. ix., p. 16. 



METHOD OF CLEANSING TYMPANUM. 449 

in the Manhattan Eye- and Ear Hospital, and which I am using 
in my private practice with great satisfaction. It is called the 
reservoir syringe (see page 132), and it is filled without any motion 
of the piston, so that the one action required is the discharge of 
its contents into the ear. On the withdrawal of the piston it 
fills itself perfectly. The India-rubber syringes sold in the shops 
will do very well for patients to use in cases of short duration ; 
in chronic cases a good metallic syringe is required. The foun- 
tain syringe is valuable where prolonged irrigation is required, 
as is also Fayette Taylor's douche. But for ordinary use the pis- 
ton syringe, made of metal, is the preferable one for the purpose 
of removing discharges from the ear. 

Unless the practitioner has had a large experience in cleans- 
ing ears, he should avoid the use of a syringe whose nozzle is 
long enough and sufficiently slender to enter the auditory canal 
as far as the junction of the bony with the cartilaginous portion. 
The slightest unexpected movement of the patient while the 
syringe is used, may cause great harm to the lining membrane 
of the canal. 

There are several methods of cleansing ears affected with 
a chronic suppurative process. That which I usually adopt 
is a combination of the suggestions of Politzer, Hinton, and 
Schwartze. It is, I think, a simple method, and capable of be- 
ing fully carried out by any practitioner, but not by the patient 
or a nurse. The personal care and supervision of a medical 
man, are necessary to the successful treatment of any case of 
chronic suppuration in the ear. This personal care need not 
always be daily, although it is better to have it so ; but it should, 
at the very least, be given twice a week, while the attendant of 
the patient is instructed as well as may be, for the performance 
of the duty of cleansing the ear in the intervening time. The 
importance of the cases for which the daily attendance of the 
physician is required, if properly set forth, will do away with 
any objections that may be made. No one certainly would ob- 
ject to the daily attendance of a physician upon a case of sup- 
puration of the cornea, and I submit that a suppuration in the 
cavity of the tympanum and membrana tympani is of equal im- 
portance, with the disease of the organ of vision. 

The method : The ear is first carefully cleansed with luke- 
warm water by means of a good syringe. The bowl to contain 
the water coming from the ear, should be held by the patient him- 
self — unless a very young child be the subject — and he pressed 
well into the glenoid fossa, when no water will he spilled. After 
this the ear is filled with lukewarm water poured from a test- 
tube, a spoon, or the like, and the meatus carefully stopped by 
29 



450 CLEANSING THE TYMPANUM. 

a bit of cotton-wool. The Eustachian tube is then inflated by 
means of Politzer's method, and to such an extent that a few 
drops of the water are forced by the side of the cotton out of the 
canal. This is, of course, conclusive evidence that the air has 
been forced through the tube into the middle ear, and through 
the hole in the drum-head into the external canal. The ear is 
again carefully syringed and examined by the surgeon. 

A long slender pipette, or Hartmann's tympanic syringe, are 
sometimes necessary to clean a tympanic cavity that is not well 
exposed because the hole in the drum-head is small. The curette 
will sometimes be necessary also, in order to cleanse the tym- 
panum from inspissated pus. 

Sometimes the use of the piston syringe is not well borne by 
the patient, the shock of the water being too great. In such 
cases the fountain syringe should be used. Instead of the thin 
bowl, that I have recommended as a receptacle for the fluid that 
comes from the canal, after having been injected, some practi- 
tioners use a vessel such as depicted in the accompanying cut — 




Fig. 96. — Vessel used in Syringing the Ear. 

the " Eiterbecher " of the Germans. It is certainly very con- 
venient on account of the fact that it adapts itself so well to the 
glenoid fossa, but it is not deep enough if any prolonged syring- 
ing is required. Then the bowl will do better, and on the whole 
I think it is to be preferred. 

I have known sad cases, where parents, in obedience to their 
medical adviser, have faithfully syringed the ears of a child 
suffering from chronic suppuration for years, but where the 
parts have not been perhaps even once, thoroughly cleansed. 
Exuberant granulations or polypi had sprung up, bony growths 
had occurred, which are positive evidences of the imperfect 
removal of pus and other hurtful material. 

After the syringing, the parts should be dried by the use of 
absorbent cotton twisted about a bit of wood, or a wire cotton- 
holder, very carefully applied, with the aural mirror on the fore- 
head, so that both hands are free. For self-evident reasons, it 
would never be proper to leave fluid in a cavity upon which 
medication is about to be applied. After you have secured 
thorough cleansing of the ears, I believe medication is of second- 



REMOVAL OF GRANULATIONS. 



451 



ary importance. Wilde's snare and Buck's curettes are the best 
instruments for removing polypi where instrumental interfer- 
ence becomes necessary. Nothing will keep up a discharge of 
pus from the ear, so persistently as a small polypus or granula- 
tion. My experience is exactly the same as that 
of Troltsch, published in his treatise on the ear, 
in the first edition of 1862, where he states that 
he has often seen a discharge of very long stand- 
ing disappear, as in the twinkling of an eye, on 
the removal of a small growth. I think the cu- 
rettes should be made with sharp edges — not 
blunt, as first sold in the shops. The profession 
is very much indebted to Buck and Politzer, for 
the suggestion of these very useful instruments 
for cleaning out the tympanic cavity and audi- 
tory canal. I hardly know how I would get on 
without them, after having enjoyed their use for 
some years. Pedunculated granulations and 
polypi, should be removed as one of the first 
steps in any continued treatment. Granulations 
with a broad base are very troublesome, it be- 
ing very difficult to remove them thoroughly, 
even when the patient is under observation for 
a long time. It is often necessary to etherize 
the patient in order to free the tympanic cavity 
from granulations. The great prerequisite hav- 
ing been accomplished, of securing a free tym- 
panic cavity, the question then is, What agent 
shall we choose for the cure of the diseased 
membrane, and, consequently, for stopping the 
discharge ? A very great deal, of late, has been 
said about the so-called dry treatment of suppu- 
ration of the middle ear. There was a famous 
peripatetic quack who practised a dry treatment 
which was peculiarly successful. He was in the 
habit of pouring in plaster-of -Paris, for the cure 
of long-existing discharge of pus from the ear, 
and the cure for a time was effectual. Much of the so-called 
dry treatment of to-day, will in some cases be as disappoint- 
ing as was its prototype. The treatment by powders is. nor 
particularly new, however. The late Mr. James Binton was 
very much in the habit of using French chalk and other pow- 
ders, and my former assistant. Dr. F. H. Rankin, of Newport, 
recommended iodoform in diseases o( the ear, in an article pub- 
lished in the New York- Medical Journal, some time after he had 




Fig. 97— Buck's 
Pipette. 



452 SOLUTIONS AND POWDERS. 

successfully used it in the Manhattan Hospital. Agnew, and 
Rider, and other authorities have long used powdered alum. 
Treatment by powders is not, therefore, a new subject, although 
some agents, boracic acid in particular, have been used only 
lately. In spite of all the claims for the exclusive use of pow- 
ders, in the treatment of the ear, and valuable as is their place 
in our therapeutic resources, I still think that instillations of 
fluids hold the first rank, and that the use of powders is of sec- 
ondary value. Whatever may be thought of this view, it is, I 
think, indisputably sound doctrine that cleansing must precede 
the use of any agents, and that thorough cleansing is impossible, 
in many cases, without the use of the syringe. 

For the healing of a diseased mucous membrane that has for 
some weeks or months secreted pus, and which is free from 
polypi or large granulations, I would advise that fluid applica- 
tions be first tried. In my practice I use sulphate of zinc, from 
one to four grains to the ounce ; sulphate of alum in the same 
proportion. Nitrate of silver I use usually upon a cotton-holder, 
from Hve to sixty grains to the ounce, or from a long, slender 
pipette adapted to the middle ear, (see Fig. 97) in the weak 
solutions. If a strong solution of nitrate of silver be used, it 
should be at once neutralized with salt and water. I also use 
alcohol, as suggested by Lowenburg, of Paris, especially in cases 
where the tissue is granular. A preparation of resorcin in cases 
where the mucous discharge exceeds the purulent, is also useful. 
Boracic acid in solution seems to me to accomplish very little. 
It is, indeed, difficult to say which are the best astringents. But 
some cases do well with any of the ordinary astringents, and 
some never cease to be the seat of the formation of pus, no mat- 
ter how long, how carefully you treat them, and what agents 
you may use. Carbolic acid and permanganate of potassium 
have proved worse than useless in my hands. 

When solutions do not act well or promptly, powders may be 
resorted to. Iodoform is valuable in some cases. My associate, 
Dr. Ely, thinks it especially useful in those cases where the 
tissues are pallid and have an indolent appearance. Well-trit- 
urated boracic acid is also a useful agent, but it is by no means 
a panacea, no matter how it is applied, or with whatsoever com- 
binations. There are objections to powders which at once sug- 
gest themselves when their use is advocated in treating diseased 
mucous membranes, like those of the nose or middle ear. They 
are not always absorbed, and they sometimes leave a trouble- 
some, irritating mass behind. Then they occasionally impair 
the hearing by mechanically obstructing the passage of the 
sound waves. While a solution is poured into the ear, and in 



SOLUTIONS AND POWDEPS. 453 

from five to ten minutes that which is not absorbed may be al- 
lowed to run out, the powder must remain until the ear is again 
cleansed, which is not for hours. A tube made from a quill, or 
one of the powder-blowers especially invented for the purpose, 
do equally well for forcing the powder into the canal of the tym- 
panic cavity. I do not employ large masses of the powder — sim- 
ply enough to give the ulcerated or carious portion a good coating. 
Solutions are usually much better tolerated by the ear when 
they are warm. A lighted gas-burner, the flame of a candle, a 
bowl of hot water, are all convenient means for heating the 
solution which is to be used. When powder is employed, the 
mirror should be used from the forehead, so that one may know 
just where it has gone, and renew the application if not enough 
is applied. 



Fig. 98. — Knapp's Powder-Blower. 

Whatever may be said in favor of certain specifics, used 
either as powders or solutions, certain cases of suppuration of 
the middle ear will remain uncured in hands never so skilful. 
They are, from their nature or their environment, incurable. A 
case of long-standing ulceration in the tympanic cavity and mas- 
toid is almost certain to involve more or less superficial death 
of the bone. When there is dead bone that cannot properly 
be removed by instruments, solutions of dilute mineral acids, 
nitric acid and sulphuric — one-quarter to one-half per cent. — 
dropped into the ear twice a day (Dr. Urban Pritchard) will be 
serviceable. An error in treatment, an injudicious mode of life, 
an undue exposure to wet and cold, may at any time cause the 
smoldering disease to blaze into a condition that is fatal to life. 
Pyaemia, meningitis, and cerebral abscess are by no means the 
infrequent ending of some of those cases. He who has found a 
panacea for all of them, is in a state of mind far removed from a 
scientific consideration, of the conditions which are to be found 
in chronic suppuration of the middle ear. 

When it is said that "a moist treatment of otorrhoea in many 
instances has a tendency to keep up rather than to check the 
morbid discharge from the ear," 1 if by this language, it is meant 
that careful cleansing of a suppurating middle ear with warm 
water, and the subsequent instillation of solutions, is in many 
instances a bad surgical method, I can only answer that this 
statement, according to my experience, is not borne (Hit by facts. 

1 Burnett: American Journal of the Medical Soienoes, January, ISSo. 



454 GRANULATIONS AND POLYPI. 

The presence of granulations and polypoid growths does not, in 
my opinion, contra-indicate the use of warm water. Their pres- 
ence does indicate, however, a necessity for their removal, either 
by the snare, the forceps, or caustics, pari passu with the con- 
stant cleansing process. Over and over again, however, have I 
seen growths shrivel and disappear, before the operator was 
ready to remove them by cutting or twisting instruments or by 
caustics, under the simple plan of cleansing the ear with warm 
water. 

I think it important to inflate the ears very frequently, from 
two to four times a week, and sometimes daily, by means of 
Politzer's method, during the treatment of chronic suppura- 
tion of the middle ear. The current of air is useful to dislodge 
inspissated pus or tenacious mucus, and it assists materially in 
the essential preliminary of all applications ; that is, a complete 
removal of the pus. Sometimes exhaustion of the air from the 
tympanum by Siegle's otoscope aids in getting the cavity clean. 
An ordinary air-bag may also be used for this purpose. Those 
cases in which there is a constant accumulation of long strings 
of very tenacious mucus, with very little pus, are exceedingly 
difficult to manage. The cause for this is to be found in the ex- 
cessive catarrh of the naso-pharyngeal space, and of the Eusta- 
chian tube, which usually accompanies this condition of the 
tympanic cavity. The mucus is so tenacious in these cases that 
not even the syringe or the cotton-holder will remove it, but the 
forceps must be resorted to. Of course, fundamental treatment 
will begin at the fons et origo, of the disease of the middle ear, 
that of the nose and throat. I need hardly say that the general 
condition is to be most carefully considered in all cases of chronic 
local disease. The practitioner will often find much to do in this 
direction, in these cases of chronic suppuration of the ear. The 
restoration of a perforated drum-head is a most interesting re- 
parative process. The ease and rapidity with which they heal 
in recent cases is startling, and even in chronic cases, we are 
sometimes agreeably surprised to see how soon a membrana 
tympani is restored, after simple cleansing of the middle ear has 
been maintained for a few weeks. 

The caustics which I use for removing granulations, are fum- 
ing nitric acid and chromic acid, as well as solutions of nitrate 
of silver, from twenty to sixty grains to the ounce. Alcohol is 
also valuable. When alcohol is employed it should be used at 
least twice a day, and warmed before it is poured in the ear. 
The application is painful for a few instants only. I usually 
cause the granulations to bleed freely, by puncturing them with 
a cataract-needle, before applying the caustics. 



SKIN GRAFTING. 455 

Burnett ' thinks that zinc-drops, may supply something which 
makes the bottom of the auditory canal favorable to the growth 
of the aspergillus or aural fungus. As proof of this, is adduced 
the fact that a fungus is sometimes found in zinc solutions that 
have been imperfectly stoppered. All the harm that fungi in 
zinc or other solutions can probably accomplish, is to weaken 
the solution. I consider this objection to zinc, or other solutions 
as unsubstantiated as yet by any facts, and doubtful even from 
a theoretical point of view, for it is improbable that the fungus 
would be poured into the ear, but that portion of the solution 
which is clear. Besides, before the growths were established, 
the next good syringing with warm water would be an efficient 
parasiticide if any were necessary. 

In June, 1878, Dr. Edward T. Ely, 2 my associate in private 
practice, made use of skin grafting in the treatment of chronic 
suppuration of the middle ear. Dr. Ely continued this practice 
in nine cases occurring among our patients, and I have repeated 
his experiments. This method of treatment is especially indi- 
cated for cases where we cannot expect a restoration of the mem- 
brane and a cessation of the discharge by the ordinary treat- 
ment. The results obtained have not been brilliant, but in two 
cases a substantial gain in the condition of the tympanic cavity 
was secured. 

This operation is available in cases where the membrana 
tympani is nearly gone, and where the discharge is at times 
considerable, but which at other times ceases. The ear is first 
carefully dried, and after due care has been taken that all the 
instruments to be used, as well as the hands of the surgeon and 
his assistant, are scrupulously clean, a small bit of integument 
is removed from the arm of the patient. 

It is carefully soaked in a solution of boracic acid, and ap- 
plied by means of a cotton-holder, silver probe, or Politzer's 
eyelet forceps to the exposed surface of the tympanic cavity. 
As many as three or four grafts may be applied. The canal is 
then gently packed with absorbent cotton, and the patient is 
advised to be very careful to avoid active exercise, riding in 
wagons, stages, or other conveyances, in which there is much 
motion, for two or three days. The grafts may be examined in 
three or four days. If union has occurred the packing should 
be continued for a few days longer. I think, from personal ex- 
perience, that this method of treatment will be of service in a 
limited class of cases, where an occasional period of suppuration 

1 American Journal of the Medical Sciences, January, 18So. 
8 Archives of Otology, vol. ix., p. 848, 



456 SKIN" GRAFTING — NITRATE OF SILVER. 

occurs in a largely exposed tympanic cavity, over which the 
drum-head cannot be made to heal by ordinary means, and 
where the discharge of pus only occurs at intervals, for ex- 
ample, during a coryza. If the grafts do not completely cover 
the exposed tympanic cavity, they may diminish the secreting 
surface. 

Berthold, in August, 1878, two months after Ely's cases, per- 
formed myringoplasty ' in two cases. The perforations healed, 
apparently as the result of a new inflammation set up by the 
manipulations and by the adhesion of a portion of the graft 
which became a portion of the new tissue. Berthold put a piece 
of court-plaster upon the drum membrane, which he allowed to 
remain there three days. The object of this was to remove the 
epithelium. The drum-head was found to be closed on the 
twentieth day. In a second case, also, a perforation was healed 
by this method. C. IL Tangeman, has also published an inter- 
esting case of reproduction of the membrana tympani by skin 
grafting. He denuded the edges of the perforation and put in 
a piece of skin from the arm of the patient, and retained it in 
position by collodion. The drum-heads were not entirely closed, 
but nearly so. 2 

In Schwartze's paper calling attention to the use of the 
nitrate of silver, in what he regards as strong solutions, he 
advises against the instillation of nitrate of silver where gran- 
ulations or disease of the bone exists. His exact words are : 
"The caustic treatment only promises a nearly certain result, 
when we may exclude with positiveness the existence of gran- 
ulations upon the exposed mucous membrane, or upon the 
remains of the membrana tympani, and when there are no 
evidences of ulceration of the bone." 3 

The experience of American otologists has been that strong 
solutions of nitrate of silver may be safely and profitably used, 
even where there are granulations and polypi. Indeed, I would 
especially recommend it for some of these cases, although I ad- 
mit that their value is often strikingly seen in obstinate cases 
of chronic suppuration, where the membrane is not yet in what 
may be termed a very proliferous condition. 

An efficient method of applying nitrate of silver to the whole 
mucous tract of the middle ear, at least to the lining of the 
cavity of the tympanum and the Eustachian tube, is the follow- 
ing : The solution is dropped into the cavity of the tympanum 

1 Monatsschrift fur Ohrenheilkunde, November, 1878. From Vortrag in Natur- 
forsclier Sammlung. Cassel, 1878. 

2 Archives of Otology, vol. xii., p. 228. 

3 Archiv fur Ohrenheilkunde, Bd. IV., p. 2. 



CLEANSING THE TYMPANUM. 457 

through the external meatus, and then forced through into the 
tube by two or three puffs from the ordinary air-bag used in 
Politzer's method. Of course the patient will taste the nitrate 
of silver, if it be used in this manner. 

Mr. James Hinton, of London, recognizing the fact upon 
which I have laid so much stress, that thorough cleansing of 
the ear is the first requirement of all treatment of chronic sup- 
puration in this part, advises the forcible syringing of the tym- 
panic cavity, by means of a syringe whose nozzle is made to fit 
into the external meatus, so as to exclude all the external air. 
He also syringed the tympanic cavity through the Eustachian 
tube, and used, both for this external and internal syringing, 
solutions of carbonate of soda, say of twenty grains to the 
ounce. I believe this latter method of washing out the cavity 
of the tympanum, was revived and applied to cases of suppura- 
tion by Dr. Millinger, of Vienna. I have found the washing 
out of the middle ear, with the solution of soda, a very useful 
adjuvant in these obstinate cases now under consideration ; for 
it must always be borne in mind, if we would avoid great dis- 
appointment, that these cases are usually obstinate, and often 
trying to the patience of the practitioner. I cannot say very 
much for the method of forcing fluid into the auditory canal, 
with the nozzle of the syringe placed hermetically into the 
meatus. I sometimes resort to it ; but I have usually found it 
rather violent in its action, as it is apt to cause dizziness and 
vertigo. 

Instead of washing out the canal with a solution of bicarbo- 
nate of soda, I think it much better to cause the patient to drop 
in a solution of say twenty grains to the ounce, once or twice a 
day. After this has had the effect of softening inspissated pus, 
the ear may be syringed with warm water. 

It is necessary and proper, in some cases that have resisted 
less active treatment, to apply the solid nitrate of silver to the 
edges of the perforated membrana tympani, as well as to the 
tympanic cavity. It is best applied on a probe, upon the point 
of which it has been fused, in a platinum cup placed over a 
lighted lamp or gas-burner. This treatment, unlike the others, 
is apt to cause pain, which usually passes away on pouring 
warm water into the ear. It is a method, however, only to be 
resorted to when other means fail. 

As has been before said, the cleansing of the ear by the 
medical attendant, should be performed about three times a 
week. If the suppuration be profuse, the patient should be seen 
daily. Here, as in other departments of otology, we meet with 
great prejudice on the part of the laity. They have been so 



458 CHRONIC SUPPURATION — TREATMENT. 

accustomed to be sent off with a prescription for a "running 
from the ear," that they are amazed at being asked to come to 
the office daily, or three times a week. Yet this will often be 
necessary, and here as elsewhere there remains some pioneer 
work to be done in the education of the people. 

Many cases of chronic suppuration of the middle ear are not 
cured because the treatment is carried on by the patient himself 
or by his friends. Very few persons are capable of thoroughly 
cleansing their own ears. No one is capable of thoroughly 
cleansing the ear of another unless a special training for this 
object has been undergone. In fact, a successful treatment of 
these cases requires the care of a physician. It is easier to learn 
to clean and dress an ordinary bone fistula, than to learn to re- 
move the secretions from an inflamed tympanic cavity and 
mastoid cells. He who would bring his cases to a successful 
ending, must himself bear the brunt of the labor of treatment. 
It cannot be given over to inexperienced hands. Whenever this 
personal care of the physician is not to be obtained for these 
chronic cases, only approximately good results are possible. I 
have sometimes been able to train a nurse or relative of the 
patient, so that quite thorough cleansing is effected. 

Besides all this, each case should be considered by itself . Some 
cases will tolerate thorough cleansing by the syringe, cotton- 
holder, and curette, while others will resent all but the most deli- 
cate handling, by fits of vertigo, fainting, and inflammatory reac- 
tion, so that a case must be studied for a few days before it can 
be definitely determined as to how much and what is to be done. 

Dr. G. M. Beard ' thought that the galvanic current was 
sometimes a powerful adjuvant in healing a suppurative pro- 
cess in the middle ear, just as it is in healing ulcers in other 
parts of the body. An electrode with a long narrow extremity, 
covered with a little cotton, is passed into the auditory canal 
through a rubber speculum. The canal is usually filled with 
warm water. The electrode is connected with the negative pole 
of the battery. The positive pole is placed either in the hands 
of the patient or at the back of the neck. Only very weak cur- 
rents and short applications are borne, and the treatment should 
be cautiously conducted. Drs. Mathewson and Prout, in con- 
junction with Dr. Beard, tested this plan of treatment in cases 
at the Brooklyn Eye and Ear Hospital. The character of the 
discharge soon begins to change under this treatment, and in 
some cases the cure seems to have been more speedy than it 
would have been without it. 

1 Verbal communication. 



CHRONIC SUPPURATION — TREATMENT. 459 

In cases of chronic suppuration of the tympanic cavity., 
where the opening in the drum-head is very small, or when 
from any other reason it is very difficult to thoroughly remove 
the pus, I have found benefit — in connection with the use of 
Politzer's method of inflation — from the use of Siegle's otoscope 
attached to a syringe, for the purpose of sucking out, as it were, 
the fluids from the drum-cavity. After all the other means of 
cleansing the part have been thoroughly used, it will still be 
sometimes found that more pus may be evacuated by the suc- 
tion method. 

Hartmann's tympanic syringe, which has been mentioned on one of the pre- 
ceding pages, is often useful in cleansing the tympanum. It consists essentially 
of a silver tube 2£ mm. in circumference and 7 cm. long. Each extremity is 
curved, the one for the tympanum at a right angle ; the curved portion is about 
one mm. long. The distal end of the tube is curved at an obtuse angle, and 
has somewhat of a funnel-shaped orifice, to which a bit of rubber tubing is at- 
tached. The tubing should be as delicate as possible, so that its weight may 
not interfere with the position of the tube in the tympanum. The water is in- 
jected by means of a Davidson syringe, affixed to the rubber tubing. 

Dr. C. I. Pardee 1 believes that the choice of an astringent 
may be regulated by the character of the secretion. If the se- 
cretion from the exposed tympanic cavity be predominantly of 
a mucous character, Dr. Pardee uses nitrate of silver. When 
the secretion is chiefly purulent, he uses weak astringents of 
sulphate of zinc, acetate of lead, and alum. It would certainly 
be a great advance did we have more certain indications for the 
use of strong or weak astringents ; but I am not prepared to 
give a positive opinion as to the correctness of Dr. Pardee's 
theory. I may only repeat what was said in substance in the 
preceding part of this chapter, that any of the well-known 
mineral astringents do very well, if the parts are thoroughly 
cleansed, and if none of the consequences of the suppurative 
process have as yet resulted. It should not be forgotten that 
the pharynx and nostrils, will often require nearly as much 
treatment as the ear. 

The surgeon who is in the frequent habit of examining the 
membrana tympani will find many cases that show how easily 
an ulcerated drum-head will sometimes heal under very simple 
or very crude treatment. Cicatricial drum-heads are a very 
common experience in the aural surgeon's observations. A little 
study of the history of these cases shows that in very many in- 
stances they were healed when they were being treated with 
what we should term neglect. All this should teach us to be 

1 Transactions of the American Otological Society, Fourth Annual Meeting, 1871. 



460 CHRONIC SUPPURATION — TREATMENT. 

very careful students of the healing processes of Nature. In 
our anxiety to see results from treatment, let us remember to 
put ourselves in the position of Ambroise Pare, whose benedic- 
tion to his wounded patient was, " I have dressed you, may God 
cure you." 

All cases of chronic suppuration of the middle ear, will not 
be cured even by good treatment and favorable conditions, 
while here and there, we are surprised to find that some un- 
promising cases do very well, even under bad circumstances 
and with no thorough treatment. To expect too much from 
treatment, to do too much, is to be meddlesome in intent and 
action. If we are to make a choice of evils, it is better to be 
skeptical and inactive, than credulous and meddlesome. 

It is an interesting fact that very few patients suffering from 
phthisis pulmonalis ever recover from a suppuration of the ear. 
Even so far as the accumulation of pus is concerned, no matter 
how long they may live, the cough usually prevents any healing 
of the membrana tympani. I have one case under observation — 
the only one I have ever seen — where the discharge and forma- 
tion of pus have ceased, although the perforation of the mem- 
brane does not close. 



THE ARTIFICIAL MEMBRANA TYMPANI. 

This contrivance is at times a valuable means of treating a 
chronic suppurative process in the middle ear. We have al- 
ready seen that a New York layman was the actual inventor of 
a substitute for the natural membrane. This gentleman used a 
bit of paper moistened with saliva for this purpose in his own 
ear, and showed it to Dr. James Yearsley, of London, who 
seized upon the idea, and gave it to the profession, substituting 
cotton-wool for the paper. Besides acting as an artificial mem- 
brane, the cotton plug is sometimes used as a means of treating 
a chronic suppurative process in the ear. It is then packed in 
the canal quite thoroughly. When it is employed for the pur- 
pose of improving the hearing, having been slightly moistened, 
it is inserted under inspection — that is, while the parts are well 
illuminated by the otoscope — by means of a pair of forceps, that 
should be very weak in the spring, so that the blades may come 
together with very little pressure, or by a probe. 1 

The appropriate position for the cotton, where it will improve 
the hearing, will be found, if it is to do any good, by placing it 
on different parts of the exposed tympanic cavity, or the re- 

1 Yearsley on Deafness, p, 245. 



ARTIFICIAL MEMBRANA TYMPANI. 461 

mains of the drum-head, until the patient experiences an im- 
provement in the hearing power. 

I have taught a number of patients to use this kind of a 
drum-head, and I have seen many others who have learned to 
use it from other physicians. In the most cases, however, 
Toynbee's disk is preferred, as being easier to manage. 

There has been quite a good deal written of the cotton pellet 
of late. This may serve to call it again to the marked attention 
of the profession. Yet nothing essentially new, has been said 
upon the subject, since Yearsley brought it fully before the pro- 
fession in his text-book. To Yearsley, belongs all the credit of 
quickly utilizing the strong hint given him by the New York 
merchant with his spill of paper, and of suggesting a practical 
use of an artificial membrana tympani. Queerly enough, an- 
other New York merchant, who had accidentally learned to 
improve his hearing by a little roll of paper, without knowing 
of his immortal predecessor, or of Yearsley or Toynbee, con- 
sulted me a few years since. 




Fig. 99. — Toynbee's Artificial Membrana Tympani. 

In 1853, Toynbee suggested another artificial membrana tym- 
pani, without knowing of the previous invention. Toynbee's 
appliance consists of a thin disk of vulcanized rubber, in the 
centre of which is attached a fine wire about an inch long, which 
terminates in a little ring, to enable the finger to more readily 
grasp it when its removal is desired. An improvement upon the 
original method of attachment of the wire, is to insert it spirally 
into the disk, like a corkscrew in a cork. 

We can never tell without trial, whether the artificial mem- 
brana tympani will, or will not improve the hearing. Inasmuch 
as I am sometimes asked if an artificial membrana tympani will 
do any good, if the membrane be intact, it may be as well to 
state, that it is only of service in cases of partial or complete 
loss of the drum-head. Von Troltsch relates a case of a deaf 
judge who used to improve his hearing temporarily by pressing 
upon the membrana tympani with a probe ; but I have never 
been able to increase the hearing power by any similar proce- 
dure upon an imperforate membrana tympani. The improve- 
ment to the hearing that does sometimes occur when the cotton- 
wool, or the membrane of Toynbee is used, is probably due to the 



462 



ARTIFICIAL MEMBRAXA TYMPANI. 



restoration of the interrupted continuity of the ossicula auditus, 
or even of the stapes alone, to the fenestra ovalis and the laby- 
rinth. Toynbee explained its benefit by stating that it occurred 
as a result of the closure of the membrane ; but this has been 
shown to be an erroneous explanation. Cases have been seen 
where the perforation was not closed by the artificial membrane, 
and yet great improvement to the hearing resulted from its use. 
When the patient first begins to wear this membrane, it should 
be used but for a very short time during the day. It is always a 
foreign body, and hence is is liable to produce irritation and in- 
crease the suppurative process. Lest any should think, that the 
artificial membrane is not a practical and valuable means of alle- 




FlG. 100. — Method of Inserting Artificial Membrana Tympani (Toynbee). 



viating some cases, I may state that I have now under observa- 
tion many patients, for whom I first introduced the membrane, 
who have worn it for years, with uninterrupted benefit to the 
hearing power. I have taught several other persons to apply the 
membrane, and with benefit ; but inasmuch as I have not seen 
them for a long time, it is not quite certain, although probable, 
that they are still using the substitute for the natural membrane. 
I am in the habit of tentatively applying the artificial membrana 
tympani in all old cases of chronic suppuration in the middle 
ear, when the loss of hearing is very great. If one ear be sound, 
so that the hearing for ordinary purposes is very good, as it 
always is under such circumstances, it is not worth while to use 
the artificial drum-head for the diseased ear. An excessive in- 
flammatory action in the remains of the drum-head, or in the 



VARIETIES OF ARTIFICIAL MEMBRAKE. 463 

middle ear, precludes any use of the artificial membrane. The 
patient for whom it is to be employed should also be an adult, and 
possessed of a considerable amount of intelligence. It is not of 
any use in the case of children, or of unusually heedless or stupid 
adults. The wire to which the disk is attached, sometimes be- 
comes separated in removing the membrane, and the disk of 
rubber is left behind. This accident, although a very insignifi- 
cant one — for the disk is readily removed by syringing — is very 
apt to frighten the patient, unless he has been previously warned 
not to be disturbed if such an accident occur, and not to allow 
any improper attempts to remove such a foreign body. 

Various modifications of Toynbee's disk attached to a wire 
have been made. Thus, Lucae attaches the disk to a small 
rubber tube. Burkhard-Merian uses a solid piece of india-rubber 
instead of a wire. Politzer, makes one especially to spare the 
poor the expense of buying Toynbee's disk. A piece \ ctm. long 
is cut from the side of an india-rubber tube 2 to 3 mm, in thick- 
ness, a hole is then made in one end and a wire handle fastened 
in it. Politzer also recommends the use of an india-rubber tube, 
as long as the canal, rounded off at the distal end and pushed 
down to the remains of the drum-head. In cases in which the 
sides of the stapes bone have been destroyed, Politzer has also 
attached a stapes bone taken from a dead body to Toynbee's disk, 
and introduces it, so that the bone lies in the niche of the fenes- 
tra ovalis, 1 with benefit to the hearing. 

Michael 2 instills glycerine, in some cases medicated With 
tannin, and then collodion, and thus forms a membranous cover- 
ing, of which he speaks highly. Hartmann 3 recommends, in 
cases where the other varieties of artificial membranae tympani 
do not prove serviceable, a noose of the most delicate and elastic 
whalebone, wound about with cotton. 

In introducing this appliance the auditory canal must be 
straightened, by pulling back the auricle, while the bone is 
placed in position, somewhat anteriorly in the depth of the canal. 
Its use requires some care, but this may be said of all artificial 
membranes ; for, as I have said, stupid adults and children can- 
not use them successfully. 

Prognosis. — The prognosis in chronic suppuration of the 

middle ear depends upon a variety of local and constitutional 
symptoms. If the consequences of chronic suppuration have 
occurred, such as exfoliation and death of bono, the formation 



1 Politzer: Text-book, p. 490, original p. 563. 

2 Transactions of International Congress, London, vol. iii., p. 434. 

3 Die Kranklieiten des Olires, p. 99. 



464 CHRONIC SUPPURATION— TREATMENT. 

of polypi, exostoses, and so on, the treatment is apt to be 
prolonged, and in some cases may never be entirely or even 
partially successful. Again, when the membrana tympani is 
entirely removed, and one or more of the ossicula lost, the prog- 
nosis is grave. Yet the membrana tympani has a regenerative 
power second to that of no other membrane of the body. I have 
repeatedly seen it entirely restored after all but a narrow rim 
had been entirely swept away. This has even occurred in cases 
of long standing. The prompt healing of the drum-head after 
operative perforation and in acute inflammation, is a matter of 
common experience. 

The state of the general system will also at times influence 
the prognosis to a marked degree. Patients with phthisis pul- 
monalis seldom recover from a spontaneous rupture of the mem- 
brana tympani. The physician will find ample material for 
general advice in some cases, and yet there are many in which 
local treatment only is required ; while it is essential in all. We 
may say, on the whole, that the prognosis can never be decid- 
edly given so long as the membrana tympani is open, for this 
membrane is essential to the safety of the ear from renewed 
attacks of acute suppuration. All our efforts should be directed, 
therefore, to closing up this opening. There can be no danger 
from closing it too soon. Our chief difficulty will be in closing 
it at all. If regular and careful treatment by a physician, con- 
tinued for months, fails to close the opening, or to cause the 
discharge of pus to cease, the patient may perhaps be given up 
as one for whom there is no hope of cure. The family and 
friends should be taught to cleanse the ear thoroughly, as long 
as any purulent inflammation occurs, and they should know 
that the chief danger to the ear, and the general system, lies in 
an accumulation and retention of pus. 

Patients suffering from an accumulation and discharge of 
pus from the tympanum cannot be too careful of their general 
health. A simple cold in the head may be fatal to them by 
causing an inflammation of the ear, followed by meningitis. 
Every year of my practice brings to my attention fatal cases of 
this kind. 

CASES. 

Case I. — Chronic Suppuration of Twelve Years' Standing — Exostosis of Tym- 
panic Cavity — Patient wider Treatment for more than Three Years — Both Mem- 

brance Tympani Healed— Hearing Distance remains the same. — W. P. H , aged 

thirty-two. June, 1869. History : Ten or twelve years ago, from some cause 
to patient unknown, the right ear began to discharge, and then the left. They 
have discharged at intervals ever since. Occasionally there is pain in the ear. 

The hearing distance is — K., || ; L., ^ 8 -. The right membrana tympani is in 



CHRONIC SUPPURATION— CASES. 465 

a state of ulceration ; about one-third is gone. The lower and posterior quad- 
rant remains. Considerable pus lies in the cavity of the tympanum. The left 
membrane is nearly gone. There is a small granulation springing from the 
cavity of the tympanum. The pharynx is tolerably healthy. 

The patient was ordered to use the warm douche daily. He visited me three 
times a week, when the ears were cleansed by the syringe and warm water, and 
Politzer's method, and an astringent, usually the sulphate of zinc, was instilled. 
In November, in about four months from the time of my first seeing him, the 
left membrana tympani had healed. The granulation disappeared with no other 
treatment than the cleansing and the use of an astringent. 

March 17, 1870. — The right membrana tympani now exhibits a clearly cut 
opening in the posterior and inferior quadrant. A small amount of pus oozes 
from it. A minute but positive elevation of bone comes out to the opening. 
The hearing is at times very poor, on account of the blocking of the tympanic 
cavity by pus. The patient has been under my observation ever since first note, 
often coming to the office every day. Nitrate of silver, nitric acid, various as- 
tringents, with the continuance of the douche and syringe, have been employed 
in vain, 

March 17, 1871. — The patient has just passed through an attack of acute 
catarrh, induced by taking cold. The hearing distance became - 4 Q »- during this 
attack. Leeches were used, and subsequently the catheter, steam being passed 
through it. After the subsidence of the inflammation, the opening in the mem- 
brana tympani was found to be very much smaller. It was then cauterized with 
the mitigated stick of nitrate of silver, melted upon a probe, and in a few weeks 
it healed entirely; so that in October, 1872, he was dismissed, with H. D. 
R., H; L., T8, and both, drum membranes healed. 

I have not attempted to give the full notes of this interesting 
but tedious case. I have inserted it to show what perseverance 
on the part of the patient will finally accomplish in some cases 
of chronic suppuration. There were no peculiar means of treat- 
ment adopted during the three years the patient was under my 
care ; but he was informed that it might require years to heal 
the drum-heads. He realized the danger from a continued sup- 
puration, as well as the inconvenience and discomfort, and he 
determined never to give up the attempt to cure it. Very few 
patients will submit to such a prolonged observation or treatment 
without faltering in their allegiance to their medical adviser. 

I have seen this patient while preparing these pages for the 
press. Two years ago he had an acute inflammation of the right 
ear, which subsided, but which left a small opening without 
ulceration. His hearing distance for the watch varies, but is 
generally very good and he hears conversation well. He is still 
actively engaged in business as a merchant, fourteen years 
since he left my care. 

Case II. — Suppuration in both Tympanic Car ides for Fifteen Fears, a Result 

of the Pharyngeal Inflammation of Scarlet Fever — No Treatment since First At- 
tack — Healing of one Drum-head, with Great Improvement to Hearing Power — 
30 



466 CHRONIC SUPPURATION — CASES. 

Other Membrane still Open. — Mr. A , aged twenty-six. November, 1870. 

Since patient was eleven years old, when he had scarlet fever, he has had a dis- 
charge from both ears, with great impairment of hearing. Hearing distance — 
right ear, t» ; left, -£%. The membranse tympani on each side are removed by 
ulceration. There is a large amount of pus in each canal, with granulations 
which bleed readily. 

The ears were treated by the warm douche, the syringe, and Politzer's 
method of inflation. The latter at once improved the hearing, so that the watch 
was heard at 4 inches, &, on the left side. Some inflammatory reaction was 
caused in a few days by the cleansing process, and the douche only could be 
employed. The patient was seen from once to twice a week, and used the douche 
and an astringent at home. One year after, his hearing distance was — E., -/»-; 
L., ft. The left membrana tympani has just healed. 

April 16, 1872, or nearly a year later, having been seen at longer or shorter 
intervals ever since, and having kept up the treatment at his home, the hearing 
distance of the left ear is f f. The patient has still occasional attacks of sub- 
acute suppuration from right ear. His hearing power for conversation is ex- 
cellent, and no true pus is found in right tympanic cavity, but some stringy 
mucus is forced out by Politzer's method. 

January, 1873. — The patient is still seen at long intervals. The condition of 
the ears remains about the same. 

Case III. — Suppuration of both Middle Ears, occurring without Pain — Half of 
each Membrana Tympani gone — Moderate Amount of Pus Secreted — Treatment did 
not avail to Improve the Hearing Power — Artificial Membrana Tympani used with 

Benefit. — E. E. T , aged twenty-eight. November, 1872. Three months since, 

patient found, on awaking in the morning, that both ears were discharging. 
There was no pain experienced in them. He had had naso-pharyngeal catarrh 
for some time, which had been treated regularly by the use of the nasal douche 
and the posterior nares syringe. The patient is not in very good general health. 
He has had a pulmonary hemorrhage, and evidently has imthisis pulmonalis. 
He hears the watch six inches on the right side, two inches on the left. Hear- 
ing distance — E , -h\ L-, - 4 - 8 -. The pharynx is granular. The anterior and inferior 
quadrant of the membrane is gone. The remainder of the membrane is white, 
and does not reflect light. The left membrane also has a large perforation, the 
anterior half being absent, and the remainder of the membrane looking like the 
right. There is a moderate amount of pus secreted in the tympanic cavity. 
The auditory canals are red and sensitive. The patient has already had more 
or less systematic treatment, and he cleanses his ears daily by syringing. There 
are great variations in the hearing power. 

The patient was seen daily for some six weeks, and efforts made to heal the 
membrana tympani by the use of sulphate of zinc, alum, sulphate of copper, 
and nitrate of silver, in solution and in solid form. Cod-liver oil was given, and 
the general condition improved, but the membranse tympani did not heal in the 
slightest, although the discharge was lessened, and the condition of the auditory 
canals was improved. 

February 15, 1873. — The patient's hearing power continued to grow worse, 
when the artificial membrane tympani were inserted, with immediate benefit to 
the hearing power, so that he could transact his business, which was that of a 
commercial traveller. Hearing distance — E., -/»-; L., -/». 



CHRONIC SUPPURATION — CASES. 467 

April 15. — The patient is still wearing the membranes with the same benefit. 
The ears are daily cleansed by syringing, and an astringent is dropped upon them. 
Mr. T says that he cannot hear " at all " without the artificial membranes. 

It has been a common observation with the patients who use 
an artificial membrana tympani, that they cannot hear as well 
after removing the artificial drum -heads as they did before 
wearing them. Yet in some cases, the improvement continues 
for hours after they are removed. The latter effect is probably 
due to the fact that the restored continuity of the ossicula and 
the fenestra ovalis is kept up, even after the agent that caused 
the restoration is removed. 

Case IV. — Chronic Suppuration of Ten Years 1 Duration Stopped in Three Bays 
by the Removal of a Small Granulation through the Drum-head, and the Application 

of Nitrate of Silver — Hearing Power Improved. — R. R . November 8, 1872 (sent 

to me by Dr. H. C. Eno). When the patient was sixteen years old he "got cold in 
the right ear ; " the ear was very painful ; it discharged and has continued to do 
so ever since. It has been under careful treatment for some months, and does 
not discharge as much as it did. The hearing distance is 1^. 

On examination, a slight amount of pus is found upon the membrana tym- 
pani. On removing this, a small granulation is seen perforating the membrane 
in the anterior and inferior quadrant. 

November 9. — The granulation was removed by means of a pair of angular 
forceps. A solution of nitrate of silver, gr. xl. ad 1 j., was applied in the open- 
ing, after a thorough cleansing of the ear by syringing and Politzer's method. 

November 10. — The opening of the membrane has closed. The patient 
remained under observation until November 22d, and suppuration did not again 
occur. The hearing distance became -jV, 

1884. — This membrane continues sound, although the patient has had eczema 
of the canal and perforation in another part of the membrane once, since the one 
here described healed. 

It may be thought that these cases illustrate the bright side 
of the treatment of chronic suppuration ; but I do not think they 
are any more than average specimens of cases of simple ulcera- 
tion, that is, ulcerations unattended by death of bone. When 
caries or necrosis of any part of the walls of the cavity has 
occurred, the prognosis is very unfavorable for a perfect arrest 
of the morbid process. I have not found so much difficulty in 
relieving uncomplicated cases of chronic suppuration, as in find- 
ing patients who were patient enough to submit to the tedious 
treatment necessary to a cure. Distrust of the advice of the 
profession is nowhere more common than in cases of chronic 
suppuration, in regard to which the laity have been taught two 
erroneous and contradictory doctrines, first, that a discharge 
from the ear is seldom checked; second, that it is dangerous to 
arrest it, if we can. 



CHAPTER XVII. 

THE CONSEQUENCES OF CHRONIC SUPPURATION OF THE 
MIDDLE EAR. 

Chronic Suppuration and its Results Inevitably Dangerous to the Health and Life of 
the Patient. — Refusal of Life Insurance Companies to take Risks of such Cases. — 
Cicatrices and Adhesions in the Tympanum. — Polypi. — Exostoses. — Mathewson's 
Operation for their Removal. — Cases. 

If a chronic suppurative process in the middle ear, remained a 
simple ulcer, with none of the consequences that are very liable 
to result from it, it would, perhaps be a condition of things to be 
preferred to a chronic proliferous process in the same part. For 
in simple chronic ulceration, the hearing power is often very 
good, the tinnitus aurium is not usually excessive, and some- 
times does not exist, and it may generally be relieved by simple 
syringing and inflation of the ear. These are the symptoms 
which are so trying, in the non-suppurative form of disease, 
that people have become insane on account of them. But the 
almost inevitable consequences of chronic suppuration in the 
middle ear, are dangerous to the health and life of the patient. 
Hence the importance of the subject, and the interest which 
every physician should take in arresting the advance of this 
disease. 

It is in view of these consequences, that English life insur- 
ance companies are said to decline to insure the lives of persons 
that are affected with chronic suppuration of the middle ear. 
A little consideration will show that any person who has a hole 
in the membrana tympani, and an ulcerative process in the 
parts beyond, has a much less chance for long life than one 
whose brain and vascular circulation are not thus exposed to 
the ravages of disease. Very few persons, comparatively, who 
suffer from chronic suppuration, live out their days, while many 
of them die very young. 

Among the possible and not infrequent consequences of 
chronic suppuration of the middle ear are — 

1. Cicatrices and adhesions in the drum-head and tympanum. 

2, Polypi. 



CONSEQUENCES OF CHRONIC SUPPURATION. 469 

3. Exostoses. 

4. Mastoid disease. 

5. Caries and necrosis of the temporal bone. 

6. Cerebral abscess. 

7. Pyaemia. 

8. Paralysis. 

CICATRICES AND ADHESIONS. 

In some fortunate cases of chronic suppuration, as we have 
seen, an end is finally reached by a closure of the membrana 
tympani. This may even occur when one or all of the ossicles 
have been removed. The impairment of hearing may be very 
great, with a neoplastic membrana tympani, but the danger to 
life and to the general health, is much lessened by a closure of 
the tympanum. Healing of the ulcerated membrana tympani, is 
therefore a result to be desired, even if the hearing be not as 
great after this has occurred, as it was when it was perforate 
and ulcerating. The drum-head, however, may not close, and 
yet its edges cicatrize and adhere to the tympanic wall. The 
tympanum then will be converted into a dry chamber, its mu- 
cous membrane so altered that it scarcely secretes, and only 
under great provocation takes on inflammatory action. It is 
sometimes difficult in such cases to determine what is left of the 
normal furniture of the tympanum, such a mass is it, of displaced 
and neoplastic tissue. If the stapes bone still remain, or even its 
foot-plate, it is sometimes possible to use an artificial membrana 
tympani with great benefit ; but generally the adhesions and 
cicatrices involve so much of the air chamber, with perhaps an 
extension into the tissues of the labyrinth, that literally nothing 
can be done for the patient, except to leave his ears to them- 
selves. Bad as this condition is, it is a more favorable one than 
when the ulcerative process still continues, with perhaps some 
one or more of the results that are now to be described. 



POLYPI. 

Celsus and Pliny, used the term polypus for a tumor springing 
from any cavity of the body. The name was adopted under the 
old system of nomenclature, when an exact knowledge of the 
nature and structure of growths or parts was not regarded in 
giving them a name. It is an unfortunate one. for there is 
scarcely any resemblance between the many -footed aquatic 
animal, after which morbid growths were called, and the exub- 
erant granulations or tumors which arise from the cavity of the 



470 POLYPI. 

tympanum and the auditory canal. It is probably too late, or 
too early, to effect any change in the nomenclature, and we 
must be content with the name aural polypi for all the growths 
that occur in the ear, except for those of an osseous structure or 
a cancerous nature. 

The best classification of aural polypi, seems to me to be that 
of Steudener, 1 who divides them into three varieties : 

1. Mucous polypi. 

2. Fibromata. 

3. Myxomata. 

To this we may add a fourth class : 

4. Angioma ; a case of which, as occurring in the ear, was 
first reported by Dr. A. H. Buck. 2 

Cases of epithelioma, sarcoma, and cholesteatoma have also 
been reported, but they do not properly belong to the subject of 
aural polypi, although they are sometimes confounded with the 
simple growths, and perhaps arise from them. For the sake of 
convenience, their consideration will be deferred until the be- 
nignant tumors have been considered. Kessel 3 also reports a 
peculiar growth, which is called a clot of blood in process of 
organization, but it hardly requires a separate classification. 

The mucous polypi are altogether the most frequent of those 
found in the ear. The fibromata, or polypi, made up of denser 
connective tissue than the mucous growths, are next in fre- 
quency. Buck, thinks that about one in ten of all the polypi 
that have been microscopically examined, belong to the class of 
fibroma. Myxoma, has been reported by Steudener only, so far 
as I have been able to find. 

Nature of Aural Polypi. — In an article published in 1864, 4 I 
attempted to show on clinical grounds, that aural polypi were 
analogous in structure to exuberant granulations, occurring as 
direct results of an ulcerative process. This view at once clears 
up the nature of these growths and takes away the fictitious 
importance which the view that regards them as independent 
tumors caused them to assume. Professor Theodore Billroth, 
in 1855, whose monograph I had not then seen, examined seven 
polypi which were found in the external auditory canal, and 
Kessel 5 quotes him as stating that the chief contents of those 
polypi were granulation material, although he states that the 

1 Archiv fur Ohrenlieilkunde, Bd. IV., p. 203. 

2 Transactions of the American Otological Society, 1870. 

3 Archiv fiir Ohrenheilkunde, Bd. IV., p. 187. 

4 American Medical Times, August 6, 1864. 

5 Archiv fiir Ohrenheilkunde, loc. cit. 



POLYPI. 



471 



existence of ciliated epithelium and the vascular network en- 
titles them to the rank of independent tumors. Billroth's idea 
as to the nature of mucous polypi is perhaps the most correct 
and the simplest. They consist of a delicate but loose stroma 
of connective tissue. In the meshes of this connective tissue 
are round, spindle-shaped, or stellate cells, and they are covered 
by a single or multiple layer of epithelium cells. 

The fibrous polypi consist of a dense connective tissue, hav- 
ing but few cellular elements in its fibres and covered by pave- 
ment epithelium. 




g*k©r 



Fig. 101.— Section of Aural Polypus, Case T. A, Layer of laminated epithelium, similar to 
that of skin ; B, B, epithelial cones, the commencement of gland formation ; (7, loose con- 
nective tissue, containing round and spindle cells and some fibres ; Z>, blood-vessels. 

Angioma is made up of newly formed vessels, or of vessels 
in whose walls are newly formed elements. It is quite a com- 
mon variety of tumor, although the case to which allusion has 
already been made, is the only one that has been reported as 
having been found in the ear. Virchow ' named the form which 
Dr. Buck examined, angioma cavernosum, because it was char- 
acterized by the existence of a network of blood spaces, occupy- 
ing the place and doing the work of capillary vessels. 

It may be said in general terms, however, that aural polypi 
are growths covered by laminated epithelium, and that they 
consist of loose connective tissue, containing round and fusi- 
form cells and a proportionately large number of blood-vessels. 
Their internal structure in some cases gives evidence of the for- 
mation of glands. 

Dr. H. C. Eno, formerly Pathologist to the Manhattan Eye 

1 Die krankhafteu Gesckwiilste, III. Bd., Hf. I., p. 307. 



472 



POLYPI. 



and Ear Hospital, and Surgeon to the New York Eye and Ear 
Infirmary, examined three specimens of aural polypi, which I 
removed from the auditory canal, and made drawings of their 
structure. These drawings will, I think, better illustrate the 
nature of these growths than further remarks. 

Case I. — Thomas G , aged twenty-three. March 14, 1871. Brooklyn 

Eye and Ear Hospital. 

History. — Seven days ago extensive swelling in meauricular region ; granu- 
lations springing out of auditory canal. 

Diagnosis. — Abscess of anterior wall of auditory canal, with polypoid growth 
arising from same point. 

Treatment. — Polypus removed and abscess opened ; ordered chloral hydrate, 
gr. xv. ; if does not sleep well to-night, to come at 12 m. 

March 16th. — Continue treatment. 

March 18th. — Touched polypus with nitric acid. 

March 21st. — Much better ; touched with argent nit. mit. 

It should be said that the usual point of origin of aural pol- 
ypi, is the cavity of the tympanum. They may arise from the 
auditory canal, but if so, they are the result of suppuration, that 
has been prolonged, or that has been augmented by the use of 




Fig. 102.— Section of Aural Polypus, Case II. A, Epithelium ; B, substance of polypus, 
made up of a mass of round cells about the size of white blood-corpuscles ; C\ C, capillary 
vessels, containing white blood-corpuscles. 



poultices, and which have rapidly broken down the integument 
of the canal, and rendered it more like its neighbor, the mucous 
membrane of the tympanic cavity. Polypi and granulations 
often, however, have their seat in the canal, but they are usu- 
ally accompanied by the same growth in the deeper parts, when 
the whole character of the tissue lining the canal has been 



POLYPI. 



473 



changed by an ulcerative process, extending from the tympanic 
cavity. As will be seen by comparing the illustrations of Case 
I., which arose from the auditory canal, with those that sprang 
from the cavity of the tympanum, the only essential difference 
is that the epithelium is thicker. 

Case II. — Maiy Jane N , aged thirteen. January 10, 1872. Manhattan 

Eye and Ear Hospital. Otitis media suppurativa, with polypus in right ear. 
Polypus nearly fills auditory canal. Discharge from both ears from scarlet 
fever since a child. Large perforations in membranae tympani. Polypus re- 
moved with snare. 




Fig. 103. — Section of Aural Polypi. A, 0, and D, same as in Fig. 101 ; E, gland lined with 
cylindrical epithelium ; F, transverse section of the same. 

Case III. — Mary Ann McC , aged fourteen. January 24, 1871. Man- 
hattan Eye and Ear Hospital. 

History. — Discharge from right ear since a child. Cause unknown. 

Diagnosis. — Otitis media suppurativa, with polypus of right ear. 

Hearing. — K., watch heard on contact. L., normal. 

Meatus. — E., full of pus. 

Treatment. — Syringed. January 31st. — Two polypi removed with snare. 
Douche and syringing. Politzer, warm douche. Nitric acid to stumps. Hear- 
ing distance increased to 2". 



Aural polypi are more rarely found by the physicians of to- 
day than by our predecessors, for the simple reason that aural 
diseases are more carefully observed, and they have no such 
opportunities to occur, as were enjoyed when a discharge of 
pus from the ear was not treated. A tumor can scarcely arise 
from a tympanic cavity or an auditory canal that is kept thor- 
oughly free from the pus of a chronic suppurative process. 



474 MALIGNANT GROWTHS. 



MALIGNANT GROWTHS. 

The malignant growths that have as yet been found in the 
ear, and which may be mistaken for malignant polypi, are epi- 
thelial carcinoma, fibrous and medullary carcinoma. Gruber 1 
relates a case where an epithelial carcinoma originated in the 
integument in the region of the mastoid bone, gradually de- 
stroyed the mastoid process, and finally reached the mucous 
membrane of the middle ear. The membrana tympani was de- 
stroyed by the growth. The patient heard a watch when laid 
upon this ear ; he had no tinnitus aurium, and so few symp- 
toms beyond extremely slight lancinating pain, that after the 
tumor had existed for three years, he still did his w^ork as a day 
laborer. 

Dr. Eobertson, 2 reports a case of supposed polypus in the 
ear, which proved to be, on microscopic examination, a specimen 
of "fasciculated sarcoma corresponding to plates of tumors con- 
stituted by embryonic tissue, found in the ' Manual d'Histologie 
Pathologique,' by Cornil and Ranvier of Paris." An attempt to 
remove the growth by cutting off pieces of it caused a hemor- 
rhage of fourteen fluid ounces in a few moments. The hemor- 
rhage was arrested by a tampon of cotton dipped in a solution 
of persulphate of iron. 

Cholesteatoma, the pearl tumors of J. Mliller, have also been 
found in the cavity of the tympanum, arising from an inflamed 
or ulcerated mucous membrane. They consist, according to 
Gruber, 3 of small degenerated epithelial cells, between which 
lie cholestearine crystals and other fatty material. They some- 
times destroy the bone by pressure, and they may even extend 
into the cranial cavity. 

Osteo-sarcoma of the cavity of the tympanum, extending 
into the auditory canal, was also observed by Boke. 4 The pa- 
tient died of meningitis. Wilde 5 reports an interesting case of 
osteo-sarcoma. A boy of seven years of age, in apparently good 
health, was brought to Mr. Wilde on account of a discharge 
from the external auditory canal. A small polypus was dis- 
covered. It was removed, but it returned quickly on the third 
day. It was again and repeatedly removed, but it recurred 
again and again, and subsequently the child was seized with an 
epileptic fit. A fluctuating point was then found upon the mas- 
toid process ; this was cut down upon at once, and the opening 
gave exit to a large amount of pus. The abscess communicated 

1 Text-book, p. 597. 2 Transactions of the American Otological Society, 1870. 

3 Lehrbuch, p. 597. 4 Gruber, loc. cit. 5 Text-book, p. 280. 



TREATMENT OF POLYPI. 475 

by a fistula with the external auditory canal. A fungous 
growth soon sprouted up through the incision. Repeated at- 
tacks of epilepsy occurred, and death soon ensued. Upon ex- 
amination there was found an osteo-sarcoma of the petrous 
and mastoid portions of the temporal bone. Wilde thinks that 
the original disease was in the bone, and that the aural dis- 
charge and fungus were but secondary appearances. The his- 
tory is not detailed enough to allow us to state with any posi- 
tiveness the first cause of the affection, but it may have been 
an ulcer in the tympanic cavity, which secondarily involved 
the bone. 

These malignant tumors of the ear should be carefully dis- 
tinguished from the benign mucous and fibrous polypi that are 
the frequent results of a neglected suppuration. Yet it should 
be remembered that the malignant growths may be also the 
result of the same original process. This fact adds to the im- 
portance of the subject. Perhaps some of the cases of death 
from the removal of aural polypi should be referred to the ex- 
tension of the malignant disease, rather than to the excision of 
a tumor from the ear. 

Treatment. — The treatment of an aural polypus should be- 
gin with the removal of the growth. I have said begin with 
deliberation, because it is a mistake to suppose that the removal 
of the polypus will be any more than the beginning of the 
treatment of the disease of which the polypus is a symptom. 
Besides, aural polypi often spring up very rapidly, even after 
they have been thoroughly removed, and when they are simple 
growths ; moreover, we are often obliged to remove them sev- 
eral times from the ear, especially where we cannot have full 
control of our patients and cause them to attend to the after- 
treatment. 

Wilde's snare, as modified by Blake (Fig. 104), will be found 
the best instrument for the removal of well-defined polypi with a 
pedicle. In Wilde's snare, the bar which carries the slide, and 
the arm which supports the wire used in cutting off the polypus. 
are in one piece. Dr. Blake has substituted a movable tube of 
German silver (d) for the fixed arm. "This tube expands at 
the outer ends into a flattened head (/), having two openings 
for the passage of the wire ; the inner end of the tube fits into 
a broad band on the slide-bar (b). The ends of the wire passing- 
down the tube are fastened to a pin on the upper part of the 
slide (c), below which is a ring, by which traction can be made." 
The instrument is better than Wilde's, because it can be turned 
in any direction without injuring the walls of the canal. A 



476 



POLYPI — TREATMENT. 



paracentesis needle may also be used in the handle, but it 
should be rather longer than the one in the cut. 

Scissors may sometimes be used with advantage to remove 
aural polypi. I have found those that are here represented very 
convenient, especially for the removal of growths from the 
walls of the auditory canal. 




PlG. 104. — Blake's Modification of Wilde's Snare, with Paracentesis Needle. 

Forceps may sometimes be employed, although I prefer the 
snare and scissors to all other mechanical means for removing 
polypi or granulations. Forceps, unless used with great gentle- 
ness and care, may wrench more than the morbid growth from 
the cavity of the tympanum, and thus do great harm. 

Very small pedunculated growths may be often removed by 
the simple angular-toothed forceps, figured on page 59 of this 
work. True exuberant granulations, having no pedicle, but 
arising from a broad surface, usually resist treatment with 
great obstinacy, because they are difficult to reach and entirely 




Fig. 105. — Scissors for the Removal of Aural Polypi 

remove with instruments, and because they usually cover cari- 
ous or necrosed bone. Caustics are perhaps the only means of 
removing such growths. The agents I usually employ for such 
cases are strong solutions of nitrate of silver — from forty to four 
hundred and eighty grains to the ounce — and fuming nitric 
acid. The nitrate of silver may be poured in upon the part, 
and then neutralized by the subsequent instillation of a solution 
of common salt. 

Dr. O. D. Pomeroy 1 reports a case of "the removal of a poly- 

1 Medical Record, vol. vi. Reported by D. Webster, M.D. 



POLYPI — TREATMENT. 



477 



I 



poid granulation of ten years' standing, by four applications of 
a forty-grain solution of nitrate of silver." A pipette was used 
to drop the nitrate of silver upon the growth. Although it is 
evident from the history that the dis- 
ease which allowed the formation of the 
polypus — a chronic suppuration from 
scarlet fever — had existed for ten years, 
it does not certainly appear that the 
polypus had been in the ear so long. 
The polypus is said to have sprung from 
the membrana tympani, which was per- 
forate, however. 

I am in the habit of treating granu- 
lations that arise from the cavity of the 
tympanum, where it is somewhat dan- 
gerous to use forceps, scissors, or snare, 
by numerous punctures with a cataract 
needle. The puncturing causes consid- 
erable hemorrhage. After the blood is 
wiped away a caustic should be applied. 
Nitric or chromic acid may be thus used, 
by means of a glass rod, a cotton-holder 
armed with cotton, or a bit of wood. 

The pain from these applications is 
usually so little that even children will 
bear them without shrinking. The 
granulations are of such a low grade of 
organization that they have very little 
sensitiveness. There are, of course, 
many other agents than those that have 
been mentioned, which may be profit- 
ably used in cauterizing the bases of 
polypi that have been removed by in- 
struments, and in destroying fungous 
granulations. Chromic acid is very 
much employed, as well as the acid ni- 
trate of mercury. 

Dr. Edward H. Clarke often injects 
a solution of the perchloride or persul- 
phate of iron into the interior of a poly- 
pus, and with the happiest results. ' Two 
or three drops of the liquor ferri per- 
chloridi, of the liquor ferri persulphatis, are injected into the 
growth by means of a hypodermic syringe. 



Fig. IOC. — Ruck's Curettes, 
for clearing auditory canal ami 
tympanum. 



On Polypus of the Ear, p. 01. 



478 POLYPI— TEE ATM EXT. 

Dr. Hackley drops a few drops of the persulphate of iron upon 
small granulations, and he informs me, that after years of ex- 
perience with this remedy, he is well satisfied with the results 
of its use. I have lately used it and I think it shrivels the 
smaller growths very well. But I now chiefly use the curette 
for small growths. 

The galvano-cautery is said to be an efficient and painless 
method of removing granulations from the cavity of the tym- 
panum. Dr. Blake does not consider it a painless method of 
perforating the drum-head however, he having witnessed its 
operation, in Vienna* in some experiments made by Politzer, 
Chemani, and Moos. Allusion has already been made to this 
means of puncturing the membrana tympani. In each of the 
cases observed by Blake, where an attempt was made to per- 
forate the membrana tympani with a galvano-cautery, the pain 
was so severe that further attempts were abandoned. It is prob- 
able, however, that it is not so painful a process when used to 
remove granulations. Schwartze 1 speaks very highly of the 
galvano-cautery for the purpose of removing morbid growths. 
Although the pain is considerable, much more severe than from 
the use of the pure nitrate of silver, the reaction is slight. 
Schwartze also believes that the galvano-cautery is a more effi- 
cient means of removing the growth than the ordinary caustics. 

No difficulty will usually be found in the removal of large or 
pedunculated polypi or granulations. It is only by those that 
are small and flat, arising from dead bone, and which are very 
rapidly reproduced, that difficulty will be found. Each surgeon 
will soon learn how he can best deal with the former variety, 
whether with forceps, snare, or curettes. The latter form, espe- 
cially if buried, so to speak, in the tympanic cavity, will often 
tax the surgeon's skill and ingenuity to the utmost. The use of 
alum will sometimes shrivel the granulations so as to cause a 
pedicle to show itself. Iodoform, as has been said, is a good ap- 
plication to pale growths. Alcohol is also valuable. It should 
be used at least three times a day, and warmed before it is 
dropped into the ear, when used for polypi. It causes consider- 
able pain, but it is only of short duration. It is well to begin 
with a fifty per cent, solution. 

Free incisions into the granulations, down to the bone, by 
means of a narrow Graefe's cataract knife, are also effective, 
especially in recent cases. 

No matter which of the methods that have been detailed, be 
employed in removing an aural polypus, the subsequent treat- 
ment will be the same. The case, after the removal of the 

1 Archiv fur Olirenlieilkuude, Bd. IV., p. 8. 



CASE OF POLYPUS. 479 

growth — if caries, necrosis, or exostosis do not exist — is one of 
simple chronic suppuration, that should be managed in the man- 
ner that has been set forth in the preceding chapter. The re- 
moval of the polypus may improve the hearing very much, or it 
may scarcely benefit it. If the polypus were a mere mechanical 
obstruction to the entrance of sound, its removal would of course 
at once restore the hearing power ; but, as has been seen, it is 
much more than that. The prognosis in regard to the hearing 
power in cases of aural polypi should always be guarded. The 
hemorrhage from their removal is usually trifling. If it be 
excessive, as in Dr. Robertson's case of carcinoma, a tampon 
saturated in sulphate of iron will arrest it. I usually employ 
Rohland's styptic cotton for the arrest of hemorrhage from the 
base of a polypus, if the use of cotton-wool do not check it at 
once. Hot water is also a good styptic. 

Blake's Middle Ear Mirror. 

Dr. Blake has invented a middle ear mirror, for the purpose 
of examining cases of suppurative inflammation of the middle 
ear more accurately than can be done with the aural speculum. 1 
It is said to be especially useful in detecting the exact site of 
small granulations. The use of Dr. Blake's instrument, as he 
himself states, "is of necessity limited to a very small number 
of cases, as both a moderately wide meatus and a comparatively 
large opening in the membrana tympani must exist, to permit 
of the introduction of a mirror of sufficient size." The instru- 
ment was first constructed to accurately determine the origin of 
a growth which was external to the membrana tympani, but 
which was hidden from view by the conformation of the external 
auditory canal. 

The mirror is attached to Weber's tenotome, the cutting-hook 
being replaced by a polished steel mirror of from one-sixteenth 
to one-eighth of an inch in diameter. In some cases Dr. Blake 
thinks a larger mirror may be used. "The mirror is made by 
flattening out the end of the shaft, bending it at the proper 
angle, tempering and polishing it. The shaft is ductile, so That 
the angle of the mirror can be varied at will. Shafts of various 
lengths, with mirrors of various sizes, may be used in the same 
handle, and the mirror may be rotated by movement of the stud 
in the handle." 

Polypus in the Auditory Caned for Forty-one Years— Femoral.— Tho most 
remarkable case of polypus in the ear, that I ever saw, was one Ghat came to me 



1 Transactions of the American Otologics! Society, 1872, p, 83. 



480 BONY GROWTHS. 

in 1875. The subject of the disease was fifty-six years old. He stated that he 
had had a discharge from his ear ever since he was a small boy, and that he was 
positive that he had had a polypus in the ear for forty-one years. The right 
auditory canal was found to be filled with a polypus, and there was a slight 
amount of pus in the canal. The j)atient stated that he had taken great care of 
his ear and his polypus during all these years. He brought with him a peculiar 
kind of cotton, which he had used to cleanse the canal and to plug the meatus. 
After I gave him the advice to allow the removal of the growth, he accepted it, 
but with many misgivings and great reluctance. He seemed to believe that the 
most serious consequences would follow the removal of the growth. It was ef- 
fected very easily by a snare. It was attached by a pedicle to the upper and 
posterior wall of the canal. The membrana tympani was whole, but cicatricial. 
The hearing power was nil. The growth did not recur, and the patient has 
suffered no evil consequences from its removal. I have no doubt, after careful 
investigation, that this gentleman's account of the number of years the polypus 
had been in his ear, was strictly correct. As Dr. Ely remarked, when we were 
advising the patient to allow the tumor to be removed: ''It was a case of a 
man attached to a polypus." 

For the benefit of the student and young practitioner, we 
may formulate our knowledge of aural polypi as follows : 

I. True aural polypi are morbid growths analogous to ex- 
uberant granulations. 

II. They are the result of a long-continued, or recent and 
violent purulent inflammation of the cavity of the tympanum 
or external auditory canal — usually of the former. 

III. Their removal is usually but the beginning, of a treat- 
ment of the disease of which they are consequences and symp- 
toms. 

IV. The hearing power of the patient will not be restored, 
although usually improved by the removal of an aural polypus. 

Y. Malignant growths occur in the ear, which assume the 
form of, and may be mistaken for, simple polypi. 



BOXY GROWTHS. 

Exostoses, hyperostoses, or bony growths sometimes occur 
in the osseous portion of the auditory canal and in the cavity of 
the tympanum. They may be divided into two great classes — 
the congenital and acquired forms. With the congenital we 
have very little to do. Inasmuch as they are not consequences 
of chronic suppuration, they do not usually, if ever, become a 
source of trouble, and are generally seen incidentally — that is, 
when a patient's ear is being examined for some disease inde- 
pendent of the exostosis. In these congenital cases the whole 



BONY GROWTHS. 481 

calibre of the canal is sometimes lessened by a general thicken- 
ing of the bone, but more frequently the growths extend from 
one point, with a pretty well defined pedicle. 

Professor S. Moos * believes that osseous tumors in the exter- 
nal auditory canal are relatively frequent, and he has observed 
three cases of the symmetrical formation of exostoses in both 
auditory canals, in persons who consulted him for a catarrh of 
the middle ear. "The tumors developed invariably from the 
upper wall of the external auditory canal, close to the drum- 
head, and opposite Shrapnell's membrane." None of the pa- 
tients had ever suffered from gout, rheumatism, syphilis, or a 
suppuration in the ear. Moos, thinks that these cases, were con- 
sequent upon irritative processes occurring at the time when the 
annulus tympanicus, unites with the squamous portion of the 
temporal bone. Dr. Gruening reported two similar cases at a 
meeting of the New York Ophthalmological Society, in April, 
1872. These congenital bony growths do not require treatment, 
and should not be interfered with. 

When the subject is old, and the auditory canal is naturally 
narrowed by the alteration in position in the lower jaw, some 
trouble may be experienced from the impaction of wax in the 
ear in cases of congenital exostoses, inasmuch as the usual 
means of its removal — the motions of the jaw — cannot produce 
the same effect upon the narrow passage. 

Bounafont 2 reports an interesting case of an aural exostosis, 
which, so far as I can judge from the history, which is not very 
detailed nor exact, seems to have been congenital, and to have 
continued to grow after birth. It completely obliterated the 
auditory canal : " Observation d'un cas de surdite complete de 
Voreille gauche dii a V obliteration du conduit auditif par une 
tumeur osseuse, siegeant pres la membrane du tympaiu et guerie 
par la trepanation de la tumeur. " There was no history of pre- 
vious pain or suppuration. By the use of a point of nitrate of 
silver, for six sittings, the bone was exposed at the centre of the 
growth, and it was then removed by boring into it with a rat- 
tail file. In ten applications of this file, which were not very 
painful, an opening was made. A whalebone probe was then 
fastened in the opening. This opening was kept up for some 
months, and after it was made the tick of the watch was heard 
for some inches. Some years after, the opening through the 
exostosis still remained. 



1 Archives of Ophthalmology and Otology, vol. ii , p. 186. 

• Monatssehri't fir Ohrenheilkunde, Jahrgang II., No. 8, hie a I'Aeadomie liu- 
p6riale de Mc'doeine, May 2G, 1868, 
31 



482 BONY GROWTHS. 

Professor H. Welcker, ' of Halle, in an article upon bony growths in the ear, 
found upon the dead subject, gives some interesting facts in regard to these for- 
mations. Welcker quotes from Seligman, who found exostoses very frequently 
in the external auditory canals of the skulls of American Indians, that had been 
misshapen by pressure exerted upon them in infancy. ' ' Of six such skulls, five 
were found to have this kind of exostosis." Seligman was inclined to believe 
that these growths were a peculiarity of race ; but Welcker does not agree with 
him, because he found them in other Indians not of the tribe whose skulls were 
examined by Professor Seligman, and whose bones had not been changed by 
pressure. Welcker also adds that these exostoses are not extremely rare among 
the cultured population of Europe, and as shown by the text-books and C. O. 
Weber's collection, the external auditory canal is a favorite position for them. 
Welcker thinks that Seligman's observations show that exostoses of the external 
auditory canal are more frequent among the Indian tribes than among the people 
of Europe, although he does not think there is any race peculiarity in them. 
The exostoses found by Seligman, in such relative frequency among North 
American Indians, seem to plainly belong to the class of congenital growths 
which have been reported by Moos, Gruening, and Agnew ; but I have no doubt 
that their origin was, as Moos states, due to some local irritation, which caused 
a proliferation of bone. 

Dr. "Victor Bremer, 2 of Copenhagen, also reports a case of removal of an 
exostosis from the auditory canal. There was a bony growth in each ear. The 
right canal was entirely closed by an osseous growth situated 22 mm. from the 
meatus. A fine flexible saw was tried, and its use given up. With a pair of 
scissors he then succeeded in cutting off a small piece of the tumor. The dental 
engine, as suggested by Dr. Mathewson, was then tried, but Dr. Bremer feared 
to continue it, fearing that he would injure the membrana tympani. The scis- 
sors were again used, and in a short time he found that he had cut through the 
tumor and the probe touched an elastic body. The suppuration was then free 
and the granulations were numerous. The granulations were touched with 
nitrate of silver. The canal was kept open for fourteen days with laminaria 
digitata. In five weeks the hearing was restored. When the hearing was com- 
plete, it was found that an oblong opening 4 mm. long had been made in the 
tumor. This case is so superficially reported that it is impossible to say 
whether the exostosis was congenital or acquired. It is more likely to have been 
the latter, and to have been the result of long-continued inflammation of the 
bony canal. 

Prof essor William Turner 3 describes an exostosis of the canal, in an adult male 
skull obtained near Pisaqua, Peru. Both passages were nearly closed by hard, 
ivory-like exostoses. These were pedunculated, and on the left side, when the 
integument existed, they must have blocked up the canal. The exostoses on 
both sides grew upon that part of the wall of the canal formed by the auditory 
plate of the expanded tympanic ring. In the adult skull of a flatheaded 
Chenook Indian, from the district of the Columbia Biver, Professor Turner 
found the right external auditory canal partially closed by a broad-based exos- 



1 Archiv fiir Ohrenheilkunde, Bd. I., p. 171. 

2 American Journal of Otology, vol. i., p. 228. Annales des Malades de l'Oreille. 



Paris, December 31, 1878. 

3 Journal of Anatomy and Physiology, xii., part 2, p. 200. 






ACQUIRED EXOSTOSES. 488 

tosis, which grew from the posterior wall formed by the tympanic plate. There 
was also a linear-shaped exostosis deeper in the canal. Professor Turner ob- 
served narrowing of the external auditory canal, in several specimens of Peruvian 
skulls not artificially deformed. 

Dr. C. J. Blake, has examined the skulls of the mound-builders of Tennessee. 
from the collection of the Peabody Museum in Cambridge, Mass. Dr. Blake 
confirms Professor Turner's opinion that the modification in the shape of the 
external auditory canal so often found in aborigines of America is not due to the 
artificial elongation of the skull induced in certain tribes by pressure in infancy. 
Dr. Blake's attention was drawn to the subject by the late Professor Jeffries 
Wyman, who found exostoses of the auditory canal in 6 out of 334 Peruvian 
crania. Dr. Blake examined 195 skulls. In 36. exostoses were found in one or 
both canals, as well as narrowing of the canals. Fifty Californian skulls, taken 
from graves in the island near Santa Barbara, were measured for the sake of 
comparison with those of the mound-builders. The average vertical diameter 
was found to be more than a millimetre greater in the former, and the antero- 
posterior diameter more than 3 mm. greater. Of 108 California crania, 5 had 
exostoses in one or both canals, and in 3 of the 5 a corresponding narrowing 
of the canal. Dr. Blake does not think there can be any positive opinion, as yet, 
as to the cause of these exostoses in the aborigines of various countries. There 
were no evidences of syphilis, in the bones of the Californians examined. He 
has found that the majority of the cases of exostosis, he has seen in aural prac- 
tice " occurred in certain families, in the male members of successive genera- 
tions, the most marked instance being in the three successive generations of one 
family in which there is no tendency either to gouty or rheumatic disease." Dr. 
Blake also examined 37 skulls from mounds in Arkansas. Exostoses of the 
auditory canal were found in 6 of the 37 skulls. Careful search was made for 
evidence of syphilitic disease, by examination of the long bones, but none was 
found. The 6, containing exostoses came from one mound. 



INFLAMMATORY OR ACQUIRED EXOSTOSES. 

The cases of acquired exostoses are a much more serious 
matter than the congenital affections of the same kind. They 
arise in the course of a chronic suppuration of the middle ear ; 
they usually grow with more or less rapidity, and they may 
finally block up the tympanic cavity and cause retention of pus 
with all its fatal results. Such a case will be found at the close 
of this section. They are the results of a local irritation, which 
has caused in the first place a periostitis, and secondarily an 
enlargement of bone. This local irritation may be either the 
constant presence of pus on the walls of the canal, or the exten- 
sion of the inflammation of the lining membrane of the cavity 
of the tympanum, a membrane which is essentially a periosteum, 
to the true periosteum of the osseous canal. 

Toynbee, was inclined to ascribe great importance to the 
existence of a rheumatic, gouty, or syphilitic diathesis in these 
cases of acquired and growing exostoses. In his work upon the 



484 ACQUIRED EXOSTOSES. 

ear, he details nine cases of bony growths in the external audi- 
tory canal, which he evidently regards as an independent dis- 
ease, and he remarks that "they seem to be the result of a rheu- 
matic or gouty diathesis." In 1866, I published four cases 1 in 
which there was no such diathesis, but in which the growths 
were general enlargements of the periosteum, and of the bone 
structure beneath. They were morbid growths consequent upon 
local irritation. A more complete experience has substantiated 
this view. Besides, a careful examination of the history of Mr. 
Toynbee's cases causes the doubt to be raised whether a diathesis 
had much to do with the formation of several of them ; while 
some of the others probably belonged to the congenital form. 
In Case III., reported by Toynbee, a discharge had existed from 
the ear for eleven years. There was a perforation of the mem- 
brana tympani. In Case VI. there was also a discharge. In 
Case VII. the exostosis was found to be the base of a polypus. 
In Case IX. there had been a discharge from the ear when the 
patient was a boy. Nine cases are reported in all ; but the his- 
tories are not very fully given. 

Virchow 2 says that local influences are in very many cases 
the exciting cause. "Some have, indeed, educed the frequent 
cases where certain constitutional diseases, especially rheuma- 
tism, arthritis, syphilis, scorbutus, rachitis, have produced bony 
tumors, as being something opposed to these local causes. Un- 
doubtedly the field of these conditions was formerly too ampli- 
fied, and we may say that scorbutus is now almost entirely 
excluded from the list of causes, and that the gouty enlarge- 
ments of bone are no growths, but only deposits ; but we cannot 
deny the influence of the other so-called dyscrasia, especially of 
the rheumatic, syphilitic, and rachitic diatheses. In spite of 
this, their influence should not be over-estimated." 

Polypi, are frequently found upon the exostoses thafc arise in 
the course of a suppuration in the ear. This is, of course, proof 
that the tissue beneath is one that has been recently the seat of 
inflammation. 

Dr. Agnew 3 has seen quite a number of cases of exostoses 
arising in cases in which the membrana tympani was sound, 
and which he believes were due to local irritation after birth, 
such as the use of instruments for the purpose of cleansing or 
scratching the canal, the formation of furuncles in the same 
part, and so forth. 

The cases of acquired exostosis, that I have seen, with very 

1 New York Medical Journal, vol. ii., p. 424. 

2 Die Krankhaften Gescliwiilste II. Bd. Halfte I., p. 73 et seq. passim. 

3 Verbal communication, New York Ophthalmological Society. 



EXOSTOSES — TREATMENT. 485 

few exceptions, arose in connection with suppuration in the 
middle ear. In one exceptional case, the exostosis was so large 
that the condition of the membrana tympani could not be posi- 
tively known, and, unfortunately, I saw the case but once. 

From all the evidence I can gather, I am inclined to think 
that all exostoses of the canal may be finally traced to local in- 
flammation. Blake's cases, in the aborigines, as well as his 
cases occurring in private practice, and my own, pretty thor- 
oughly dispose of syphilis as a prominent cause. I do not think 
the evidence for a rheumatic diathesis as a factor, has as yet 
been made tenable. All the cases of which we have full his- 
tories, go to sustain the view, first clearly and fully put forward 
by myself, of local irritation as the determining cause. To this 
theory I still adhere. Troltsch, in the first edition of his book, 
also remarks that he usually considers the growth of exostoses, 
an incident of catarrh of the tympanum. 

Treatment. — The treatment of exostoses, unless they are so 
large as to prevent access to the tympanum, should begin by a 
treatment of the suppuration that has caused them to appear. 
If we cannot heal the perforated and ulcerating membrana tym- 
pani, as may be the case, we should keep the middle ear scrupu- 
lously free from pus, so that no blocking-up may occur. The 
patient should be taught to cleanse the canal and tympanum. 
Small growths may be painted with the tincture of iodine. If 
the exostoses are large enough to close, or nearly close, the canal, 
Mathewson's operation for removal of these growths by a drill 
in a dental engine should be performed. Dr. Mathewson first 
performed this operation upon Case VI., here reported, in 1876. l 

The machine used was Elliott's suspension dental engine. 
The patient was under ether. The integument covering the 
growth was first removed by a dental instrument known as a 
scaler. The bony growth was then perforated at several points 
near its centre with small drills about one and a half millimetre 
in diameter. The larger drills, 2-J to 3 mm. in diameter, were 
next used to enlarge the openings. The probe, on account of the 
great bleeding, was the chief guide in the operation. "The ex- 
cavation was continued cautiously," says Mathewson, "till the 
largest drill — about three millimetres in diameter — passed freely 
through with room to spare." The operation consumed about 
half an hour. The purulent discharge, that ensued was treated 
by the warm douche and a weak solution of nitrate of silver 
subsequently. The swollen and granulating soft tissue finally 

' Report of the First International Otological Socittty, p. SO. NVu York: R Apple- 
ton &Co., 1877. 



486 EXOSTOSES — CASES. 

shrivelled and disappeared, and the discharge ceased, with a good 
opening, through which the posterior and lower part of the drum- 
head could be seen. The hearing arose nearly to the normal 
standard. After Mathewsons brilliant result, his operation was 
generally adopted. Field, of London, seems to have had the 
most experience in the use of the dental engine for the removal 
of exostoses. 1 His results, justify all that Mathewson claimed 
for the operation. 

If the membrana tympani be intact, as it is in many cases of 
bony growths, even in those where there was at one time sup- 
puration in the tympanum, the cases are much easier to manage. 
There being no pus to rest upon them, they do not usually grow, 
and if the ear be kept carefully clean and free from wax, they 
need not be interfered with. 



CASES. 

The following cases will give a fair idea of the course of 
bony growths that are consequences of chronic suppuration and 
chronic inflammation : 

Case I. — Mr. C , aged thirty-nine, was seen in April, 1864, in consulta- 
tion with Dr. C. E. Agnew, under whose care he had been for some time. He 
had lost, before coming nnder observation, the hearing of his light ear by in- 
flammation and caries of the middle and internal ear. Previous to the above 
date, Dr. Agnew had removed a sequestrum, consisting of the cochlea and semi- 
circular canals, from the depths of the external auditory canal of the ear, and 

thus terminated the inflammatory action. In early life Mr. C had also 

suffered from "inflammation" of the left ear, producing the bony growths in 
the external auditory canal, which render his case the subject of present de- 
scription. He now hears with this ear a watch tick at a distance of five inches. 
In the auditory canal, near the meatus, are two bony enlargements, which rise 
from the anterior and posterior walls, and project in a conical form, so as to 
occupy at least three-fifths of its calibre. These tumors have all the physical 
appearance of exostoses, and seem to have originated in periosteal inflammation. 
They have been steadily treated for many weeks by the local application of the 
saturated tincture of iodine, and certainly not diminished in size. Pressure 
upon them excites pain and induces an increase of swelling in the skin which 
covers them, and thus temporarily adds to the deafness. The entire absence of 
hearing in the fellow-ear, and the failure of simple means to render the exos- 
toses smaller, have suggested the propriety of some surgical operation for their 
removal. Such a proceeding has been thus far postponed by the occurrence of 
an acute attack of inflammation in the parts, extending to the tympanum, with 
symptoms of more than usual cerebral irritation. From this disagreeable com- 
plication he has entirely recovered under Dr. Agnew's care. 

His general health being impaired, he went abroad, and while in London 



Diseases of the Ear, p. 57. 



EXOSTOSES — CASES. 487 

consulted Mr. Toynbee, who used bougies, hoping to dilate the canal ; but, ac- 
cording to Mr. C 's statements, they caused much pain and accomplished 

nothing. Through Dr. Agnew's courtesy, I again saw the patient in the spring 
of 1865, and found that the growths had so much increased that only a small 
probe could be passed between them, and the hearing more impaired. The 
patient could still, however, hear the watch tick, but only when laid on the 
auricle. 

The patient whose case is here given, died about two years 
after, of inflammation of the membranes of the brain, induced 
by suppuration in the cavity of the tympanum, the pus not be- 
ing able to find an outlet on account of the presence of exos- 
toses. Dr. Agnew exhibited the brain and temporal bones before 
the New York Pathological Society. The history of the other 
ear of this unfortunate patient will be found in the section on . 
caries and necrosis. 

Case II. — A gentleman, aged forty, whom I saw but once, in June, 1864. 
He states that he had a ' ' running " from his right ear for a number of years. 
For some two or three years past he had observed that the ear was stopped up. 
He was accustomed to remove the accumulating discharge by thrusting in a 
match armed with cotton. There is seen a bony growth arising from the pos- 
terior wall of the meatus, and involving the whole calibre of the canal, except a 
space large enough to admit an ordinary-sized silver probe. Through this open- 
ing a slight amount of purulent discharge constantly makes its way. There was 
some hypersemia of the pharynx, and there was a small ulcer on one of the ton- 
sils. The patient was in excellent general health, was rather a free liver, and 
said he had constitutional syphilis ; but no good evidence of its existence now 
existed. The patient had never had rheumatism or gout. 

Case III.— Mr. S , aged twenty-five, Connecticut. February 6, 1865 (a 

patient sent to me by Dr. Alfred North, of Waterbury, Ct ). When the patient 
was three or four years of age he had scarlet fever, at which time his ears began 
to discharge, and they have continued to do so at intervals ever since, with 
attacks of pain in the ears, which sometimes lasted for weeks, and prevented 
him from any occupation for the time. Eight years ago his ears were examined 
and polypi discovered, one of which was removed by caustics. The attacks of 
pain have continued to occur, the discharge continues, and his hearing is be- 
come more and more impaired. He is just now suffering from acute pain re- 
ferred to the left ear. He hears the watch about one inch from each car. 

In the right meatus there is seen a bony growth reaching nearly out of the 
orifice of the external meatus, and arising from the posterior wall. The space 
between the growth and the anterior and upper wall is about large enough to 
admit of the introduction of a camel's-hair brush. In the left meatus there is 
seen a gelatinous granulation, also reaching nearly out to the orifice of the 
meatus. 

On blowing air into the cavity of the tympanum, by means of the Eustachian 
catheter, air and fluid are heard making their exit into the external meatus; bli- 
the blocking up of this passage prevents their emergence. On the righ: side 



488 EXOSTOSES— CASES. 

pus may be seen in the orifice between the bony growth and the wall of the 
meatus. 

The confinement of the fluid in the middle ear accounts for the pain in the 
left side, and the indication of treatment was to secure its free exit. This was 
done by removing the gelatinous growth by torsion, the patient being ether- 
ized, and rendering the Eustachian tubes permeable by the use of the well- 
known means — the catheter and Politzer's method. The granulation was found 
to have its origin from a general bony expansion of the meatus. This growth 
had no one point of attachment, but involved all the sides of the meatus, 
somewhat more expanded externally, giving the bony canal rather a funnel- 
shaped appearance. The bone was roughened. The pain in the ear disappeared 
as soon as these means had been taken for securing an outlet to the pus, con- 
stantly secreted from the cavity of the tympanum, and passing through the per- 
forated membrana tyinpani, and the hearing was so much improved that the watch 
was heard about four inches from the left auricle. He remained under treat- 
ment for a few days, and then returned to "Waterbury, and has been under the 
careful and able observation of Dr. North, who has applied remedies of various 
kinds to the left meatus, the patient keeping the Eustachian tubes permeable 
by means of gargles and Politzer's apparatus. The last time I saw the patient 
was in October of this year (1865), when the following note was made : "He had 
had no attack of pain in the ear since the first date. There is still a consider- 
able discharge of pus from each ear. He hears ordinary conversation well, and 
the watch ten inches from his left ear, and two inches on the right ; a gain of 
one inch and nine inches respectively." The bony growth on the right side has 
not increased any, and that on the left is now smooth, and has a somewhat 
glistening appearance. June, 1868. — Patient still remains free from any disturb- 
ing symptoms. 

Dr. North writes me, March 25, 1873, that "the patient's general health is 
good. He hears ordinary conversation readily, and Dr. North's watch eight and 
one-half inches from the left auricle and one and one-half from the right. The 
bony growth has a smooth, shiny appearance, and only admits the passage of an 
ordinary-sized probe. The discharge from the ear is slight and of a watery 
nature. He has no pain in either ear. Any increase of the impairment of 
hearing is always relieved by an application of tincture of iodine to the bony 
growths." 

Case IV. — Woman, aged twenty-seven, at the New York Eye and Ear Infirm- 
ary. No reliable history could be obtained from the patient as to her ears, 
except that she had been occasionally hard of hearing for some years. She was 
quite sure that she never had had a discharge from the ears ; was in good gen- 
eral health, and had always been so. She could hear the watch two feet from 
the left auricle, and twelve inches from the right. The left membrana tympani 
showed evidences of previous inflammatory action, there being thickening of its 
mucous and fibrous layers. There is a bony enlargement of the posterior wall 
of the right meatus, so large as to prevent any view of the membrana tympani. 
The patient was seen but a few times, not continuing under treatment. 

Case V. — Mr. W , aged twenty-three, a patient sent to me by Professor 

Fordyce Barker, of this city. Had scarlet fever when young, and since that 
time has suffered from purulent discharge from the ear, and has been quite deaf. 



EXOSTOSES — CASES. 489 

General health is excellent. No gouty, rheumatic, or other diathesis. Hears 
ordinary conversation very near at hand with very great difficulty. The watch 
is heard when pressed upon the right meatus ; not at all on left. A gelatinous 
polypus was found attached to the hypertrophic posterior wall of the auditory 
canal. It was removed by torsion, and nitric acid applied to its roots. On left 
side there is a pedunculated bony growth, arising from the posterior wall, nearly 
occluding calibre of canal. Naso-pharyngeal catarrh. June, 1868. — Patient has 
been under observation since first date. Now hears conversation much better ; 
watch at a distance varying from one to two inches on right side. Secretion of 
pus, which when patient was first seen was profuse, is now slight. Growths 
remain the same. 



Case VI. —Miss , aged twenty-five. March, 1873. I was asked by Dr. 

E. G. Loring to assist him in the examination, under ether, of a case of tumor 
blocking up the external auditory canal, with a view to its removal if practicable. 
The tumor was so sensitive to the touch of a probe that no thorough examina- 
tion could be made. The patient was about twenty-five years of age, and had 
suffered a great deal from what she called rheumatism of the back, but which 
seemed to have been neuralgia. She was rather small and delicate, but in fair 
general health. She was placed under the influence of ether, and a thorough 
examination was made by Dr. Loring, Dr. Pardee, and myself. The tumor 
arose from the posterior portion of the osseous canal of the right ear, and nearly 
occluded the passage. There was a minute opening between it and the anterior 
wall, through which a No. 2 Bowman's probe could be passed into the cavity of 
the tympanum. The tumor was of bone, and covered by a movable integument, 
which was red and very sensitive. On passing the probe into the minute open- 
ing that has been mentioned, it could be passed under the growth, and when 
pressed upon the growth was seen to move slightly. 

The history of the case was, that there were frequent attacks of pain in the 
ear, without discharge, until the patient was eleven years old, since which time 
there has been no true "earache," and no discharge, although the parts are 
tender, and there is a great feeling of fulness in the ear. The watch is not 
heard at all on the affected side. The tuning-fork is heard better than in the 
other ear, which is normal. The examination, during the anaesthetic state, of 
the tumor by the probe, caused it to be very sensitive when the patient recov- 
ered from the ether. The aural douche was used to quiet the pain. The pa- 
tient was advised to continue to use the douche ; but inasmuch as there was no 
pus in the tympanic cavity, and the removal of the growth seemed to involve 
considerable danger from periostitis, any further treatment was delayed until 
urgent symptoms should arise. May 8, 1873. — There is considerable pain in the 
depth of the ear, and Dr. Loring and I advise that some operative means be 
taken to remove the growth. 



The history of this case indicates that there was originally 
a suppurative action, for we can hardly believe that very severe 
pain occurred so frequently as was stated, until the patient was 
eleven years old, with no suppuration. The exostosis, which 
probahly then began, has been growing ever since, until it has 



490 EXOSTOSES— CASES. 

reached the present limits, where it seriously threatens the fu- 
ture of the patient. 

The danger which seemed to exist, when I wrote the fore- 
going paragraph, was happily averted by Dr. Mathewson's first 
operation with the dental engine. The case came into his hands 
in 1876, and he devised and executed a method of removing 
these bony growths, which as yet remains the best that has ever 
been suggested or performed. 

Case VJLL — October 23, 18S3. Miss , aged twenty-one. When seven 

years of age she had scarlet fever ; both ears discharged excessively during the 
progress of the disease. Had loss of motion of the right side for thirteen 
months after. The left ear still discharges. There is no aerial conduction on 
the right side and the bone conduction is better than the aerial on the left side. 
Hears the voice about one foot from the left side. There is a bony growth in 
the left auditory canal, arising from the posterior wall and about half closing the 
opening into the tympanum. There is no drum-head in either ear. 

Case YTIL— March 6, 1884. Mr. A. J , aged thirty-eight (sent to me by 

Dr. Jones, of Chicago). When the rjatient was eighteen years old, the left ear 
was injured by the explosion of a cannon near his ear. He was thrown into the 
water, and did not think of his ear for a day or two. He .then observed that he 
could not hear well. His ears have never been quite right since, especially 
at times. His hearing distance is: E., ^; L., l £§. The tuning-fork is heard 
much better in each ear by bone conduction. There are small bony growths aris- 
ing from the anterior wall of both auditory canals. The membrante tympani are 
opaque on each side. The patient was not sure as to whether he had ever had 
a suppuration in his ears. He had chronic naso-pharyngeal catarrh as well as 
a decided inrlammation of the middle ears. There was no evidence of the ex- 
istence of either syphilis, gout, or rheumatism. 

Dr. Cocks reports a an interesting case of a pedunculated bony 
growth in the auditory canal, which formed the base of a poly- 
pus. It was so like. a polypus in appearance, that a snare was 
put about it. and it was fortunately broken off. The growth 
sprang from the posterior wall of the canal, at the junction of 
the osseous and cartilaginous portions. 

1 Archives of Otology, vol. xii. , p. 59. 



CHAPTER XVIII. 

THE CONSEQUENCES OF CHEONIC SUPPUKATION OF THE 
MIDDLE EAE— ( Continued) . 

Diseases of the Mastoid Process.— Periostitis. — Caries and Suppuration. — Trephining 
or Opening the Mastoid. — Historical Account of the Operation.— Cases. 

THE DISEASES OP THE MASTOID PROCESS. 

As we have seen, in considering the diseases of the middle ear, 
and in discussing its anatomy, the mastoid process is necessarily 
involved in any severe inflammation of the tympanum. This 
may also be the case in an acute or chronic inflammation of 
the auditory canal, for the mastoid process opens into this part 
also. Yet there is a form of inflammation of the mastoid pro- 
cess, which assumes such importance, and overshadows the in- 
flammatory action in other parts, to such a degree, that it de- 
mands an especial study, and especial treatment. The usual 
treatment of an acute inflammation of the external and middle 
ear soon causes the symptoms of the inflammation of the lining 
membrane of the mastoid cavities to subside ; but when the 
mastoid process is involved in the course of a chronic suppu- 
rative process, the ordinary treatment will not avail. More 
prompt and decisive means are usually required. Under such 
circumstances, diseases of the mastoid often assume such pro- 
portions of severity and danger, that we are justified in speak- 
ing of them as independent affections requiring especial notice 
and treatment. Severe disease of the mastoid is a complication 
or consequence of chronic suppuration in the middle ear. only 
second in gravity, to an extension of the inflammation to that 
portion of the dura mater covering and running into the tym- 
panic cavity. 

The diseases of the mastoid process that may arise as a con- 
sequence of a chronic inflammation of the middle ear may be 
divided into the following varieties : 

1. Inflammation of the periosteum. 

2. Caries, with formation of an abscess in some part of the 
cavity. 



492 MASTOID PERIOSTITIS. 

It is true, as has been already indicated, that the first form 
often arises in the course of an acute catarrh, and that it perhaps 
always exists to a more or less extent in this disease ; but it is 
no less true that a chronic suppurative process that has been go- 
ing on quietly for years perhaps, will suddenly become an acute 
inflammation of the mucous membrane and periosteum of the 
part, and require especial and prompt treatment. The mucous 
membrane lining the mastoid cells is so closely connected to the 
bone, that, like the mucous membrane of the cavity of the tym- 
panum, it is essentially a periosteum. 

Caries and necrosis, are of course the same affections that 
occur so frequently in other parts of the middle ear, and from 
the same cause — imperfect removal of pus. 

Sclerosis or hyperostosis should also be mentioned as one of 
the results of chronic inflammation of this part. During the 
operation for perforation of the mastoid it is often found, as 
shown by Agnew's case, 1 and subsequently by Buck's 2 and 
Schwartze's 3 statistics, in a state of sclerosis. Anatomical inves- 
tigations indicate, that this is oftener a congenital rather than a 
pathological condition. If the bone is not pneumatic, it is cer- 
tainly in a worse condition for the reception of a chronic inflam- 
matory process, than if it were full of air-cells. 

Disease of the mastoid is usually seen in plain connection 
with an affection of the tympanum. In the nature of things 
this must necessarily be so, for the mastoid process and the 
tympanum are merely parts of one anatomical space, and no 
complete separation of their inflammations is possible. But this 
is not always so. A few weeks ago, I evacuated a drachm or 
more of pus from the mastoid cells of a young child, through the 
auditory canal, while the membrana tympani remained intact and 
apparently uninjured. The patient made a good recovery, and 
although I could not determine on account of the patient's age 
— she was about three years old — whether or not there was a 
catarrh of the tympanum, there was certainly no serious inflam- 
mation except in the mastoid. It was markedly red, swelled, 
and tender. From the history, given by the child's mother, I 
do not doubt, that the case was one of suppuration of the mid- 
dle ear, especially affecting the mastoid portion of this part. 
Other cases of so-called primary periostitis have been published, 4 



' Transactions of the American Otological Society, July 20, 1870. 

" Treatise on the Ear. 

3 Archiv fur Ohrenheilkunde, Bd. IV. -XX., passim. 

* Knapp: Report of International Otological Congress, New York, 1876, p. 80. 
Gruening: Medical Record, June 4, 1881. Cornelius Williams: Archives of Otology, 
vol. xiii., p. 22. W. Cheatham: Louisville MedicalJournal, October 26, 1878. 



MASTOID PERIOSTITIS. 493 

but a careful reading of the histories shows that while the per- 
iosteum of the mastoid, was undoubtedly more severely affected 
than the lining membrane of the other parts of the middle ear, 
it is by no means certain that the mastoid inflammation was not 
actually secondary to that of the tympanum, although the latter 
may have run its course, by the time the former was under full 
headway. Buck 2 also doubts if we may correctly speak of a 
primary periostitis of the mastoid process. He says that he has 
never seen a case, to which he would feel justified in giving the 
title of primary idiopathic mastoid periostitis. Buck explains 
the cause of the apparently primary cases of mastoid disease, 
occurring in young children, as I do, in supposing that the pus 
from the tympanum found an easier escape through the mastoid 
than through the membrana tympani. Mastoid periostitis, as 
well as caries and abscess, are usually results of disease of the 
Eustachian tube and the tympanum. 

Symptoms. — The symptoms of mastoid periostitis are usually 
so distinct as to arrest the attention of the medical adviser as 
soon as they occur. 

During the course of an acute or chronic suppurative process 
in the middle ear, the patient begins to complain of great pain 
behind the ear, the mastoid process becomes red, tender, and 
swelled. This is the usual course, although at times the pain is 
not referred especially to the mastoid, even when it is evidently 
involved, as shown by the redness or tenderness of the part. 
The pain is usually of the severest kind, preventing the patient 
from sleep and from his usual occupations, although he may not 
be confined to the house. 

One of my cases, reported on a subsequent page, as well as 
others, shows that an inflammatory process may extend to the 
periosteum of the mastoid, without pain or tenderness of this 
part, but there are then symptoms in other parts of the skull, 
especially in the occiput, which considered in connection with 
the inflammation of the middle ear, will keep the surgeon on his 
guard. Besides, these cases are entirely exceptional. 

The early diagnosis of this affection is by no means an un- 
important matter. A delay in the recognition of the true state 
of things, allows of the extension of the disease to the brain 
through some of the numerous foramina which transmit the 
minute branches of the middle meningeal artery. Fus may 
also be carried into the circulation through the mastoid vein 
winch passes to the lateral sinus. 



1 Diseases of the Ear, p. 355, 



494 MASTOID PEEIOSTITIS. 

' Dr. Orne Green ' has shown, by the report of three cases, that 
phlebitis of the emissory veins of the mastoid may occur in the 
course of inflammation of the middle ear and lateral sinus 
oftener than has yet been observed. Dr. Green quotes cases 
from Kolb, Taylor, Moos, and Burchardt-Merian, which indi- 
cate this. 

In Green's cases, the phlebitis was due to an extension of an 
inflammation of the lateral sinuses. In all of the cases the 
"prominent and characteristic symptom was the peculiar indu- 
ration of the tissues of the neck, such as characterizes a cellulitis 
dependent upon phlebitis, and one of the best examples of which 
is seen in phlegmasia alba dolens." Death occurred in all of Dr. 
Green's cases. In one of them, so far as could be determined 
by the history, there was no external periostitis, but no autopsy 
could be obtained in any of the cases. It is probable that phle- 
bitis of the emissory veins is more frequently a consequence of 
disease of the mastoid process than has hitherto been supposed. 

Professor Alfred C. Post, of this city, who was one of the 
first surgeons in this country to give diseases of the ear the 
same attention that was paid to other parts of the body, has 
seen several cases where disease of the brain and death have re- 
sulted from the non-recognition of mastoid disease, as I learned 
from his lectures during the sessions of 1856-59. 

Many neglected cases run their course, however, with great 
suffering to the patient, and with much loss of function, with- 
out destroying life. This is proven by the frequency with which 
mastoid cicatrices are seen in our aural clinics. The history of 
such patients usually shows that they have had a narrow es- 
cape, but that nature has at last given relief by an external 
opening through which the pus and dead bone made their way. 

Treatment. — The treatment of mastoid congestion and peri- 
ostitis is very simple. If the symptoms, although positive, be 
of a mild type, from two to six leeches should be placed upon 
the mastoid. After the bleeding has subsided, a poultice should 
be applied. The patient should be kept in-doors and in bed. If 
the pain and tenderness are not relieved in twenty-four hours, 
an incision should be made through the integument and perios- 
teum down to the bone. The incision should be from below 
upward, lest the knife should slip and pass into the tissues of 
the neck. The opening should not be a puncture, but a cut of 
from three-quarters to an inch and a half long, or even longer, 
according to the age of the subject. The incision should be 

1 American Journal of Otology, p. 187. 1879. 



495 

parallel to the attachment of the auricle. Even if the posterior 
auricular artery be wounded, the bleeding can be readily ar- 
rested by pressure or torsion. I have never found any alarming 
hemorrhage. A free escape of blood is desirable. The surgeon 
who has not made this incision in cases of mastoid periostitis 
will, perhaps, be surprised at the depth of the tissues when they 
have become infiltrated from an inflammatory action of some 
days' standing. I have sometimes been amazed at the depth to 
which the scalpel entered, especially when pus has formed. Pus 
will not be found in the majority of the cases, but the indica- 
tions for an early, free, and deep incision are imperative when 
we find redness, tenderness, and swelling of the mastoid process 
in connection with an inflammatory process in the ear. 

It is only when the symptoms are not severe, although posi- 
tively existing, that a little delay, that is of a few hours, may 
be admissible for the use of leeches, and the careful continuous 
application of poultices. If the symptoms are decidedly ameli- 
orated in a few hours, still further delay is justifiable. This, it 
should be said, however, is only true of cases of a mild type. 

In view of the dangerous character of mastoid periostitis, it 
will be better to err on the side of a free and thorough incision, 
the so-called Wilde's incision, from Sir William Wilde, who first 
advised it, — than to be too late in other cases. The cases that 
have been reported as recovering without the knife and from 
internal medication, by the use of such drugs as the sulphide 
of calcium, are, in my opinion, cases such as have recovered 
in my hands, as well as in those of my colleagues at the Man- 
hattan Eye and Ear Hospital, without any drugs whatever. To 
keep a patient in bed, and in a quiet room, with proper ventila- 
tion and warmth, and besides to nourish him well, and to use 
poultices and the warm douche, is to institute a very thorough 
treatment for many diseases of the ear. Beyond these means, 
in many cases nothing is required — and without them nothing 
whatever can be accomplished. 

Although I have classified periostitis and caries of the mas- 
toid, among the consequences of chronic suppuration, it goes 
without saying, that it sometimes arises in the course of acute 
and primary disease. It should also be understood that when it 
occurs in chronic suppuration the acute symptoms also affect 
the tympanum. 

There is a phlegmonous inflammation of the skin and connec- 
tive tissue over the mastoid, especially in young subjects, gener- 
ally arising from disease of the auditory canal, which is never 
serious, although painful. A little experience in the differentia] 
diagnosis of diseases of the middle and external ear, will soon 



496 MASTOID PERIOSTITIS — TREATMENT. 

enable the practitioner to distinguish these harmless cases of 
swelling and tenderness of the skin and connective tissue of 
the mastoid from periostitis. Furuncles, and other inflamma- 
tions in the auditory canal may cause an oedema and inflam- 
mation of the parts about the mastoid, that will not require an 
incision. A little care in observation will show, however, that 
while these cases simulate a periostitis in the swelling and red- 
ness, there is not the exquisite tenderness and dreadful suffer- 
ing of a true periostitis. The mastoid gland may enlarge during 
the course of an acute catarrh, or in strumous subjects who 
have no aural disease, but such an enlargement will hardly be 
mistaken for a periostitis. 

If the incision be made in the early stages of mastoid peri- 
ostitis, pus will not be found, but the relief to the pain from the 
hemorrhage, and from the letting up of the great tension of 
the inflamed periosteum, will be no less marked than if sup- 
puration has occurred. The incision will be as useful as the di- 
vision of the periosteum in a case of paronychia — a comparison 
which Dr. Post has been in the habit of making in lecturing 
upon these cases. 

After the incision, a poultice should be applied, and the open- 
ing maintained by the insertion of a tent a longer or shorter 
time, according to the severity of the accompanying symptoms. 
The importance of maintaining the opening for some time in 
cases of chronic suppuration, was very well illustrated by the 
following case : 

In June, 1872, I saw in consultation with Dr. E. G. Loring, a 
somewhat remarkable case of chronic suppuration in the middle 
ear, with mastoid periostitis, in a gentleman of more than seventy 
years of age, in which the opening was maintained by Dr. Lor- 
ing, by means of trimming up the edges with scissors, the use 
of caustic, a drainage-tube, and so forth, for some three months. 
Dr. Loring found that the instant the opening was allowed to 
close, pain in the back of the head, and in the depth of the ear, 
began to recur, which threatened even the life of the old gentle- 
man who was the subject of the disease. The patient finally 
made a perfect recovery from the mastoid disease, and he is ac- 
tvely engaged in the daily care of large business affairs. The 
mastoid periostitis in his case was a consequence of an un- 
usually severe acute suppuration of the middle ear, which 
swept away the drum-head in a short time. 

The treatment of the greater number of cases of periostitis is 
not usually so tedious as the case just reported. With the inci- 
sion and a few hours of poulticing, if the bone be not diseased, 
the acute symptoms subside very rapidly, and the patient is soon 



MASTOID PERIOSTITIS — CxVSES. 497 

about his usual affairs. Although patients are generally to be 
confined to their room, or house at least, during the time of the 
acute symptoms, some of them go about enough to visit the sur- 
geon at his consulting-room, especially in the spring weather, 
and with no bad results. 



CASES. 

Case I. — Periostitis of the Mastoid from Acute Suppuration — Recovery without 
Incision. — E. S , aged nineteen. July 25, 1884. One week ago, after bath- 
ing he had pain in his right ear, -which has continued at intervals. He now has 
severe pain referred to the forehead and the neck. The patient is thin and 
haggard. H. D., B., - 4 Q o ; L., \%. The bone conduction is better than the aerial 
in the right ear, and the reverse is true of the sound ear. Eight auditory canal 
swelled. Eight membrana tympani swelled and red. There is tenderness over 
the whole surface of the mastoid and down into the neck. On inflation the 
hearing distance of the ear increased to ~. The patient was seen by my asso- 
ciate, Dr. J. B. Emerson, in consultation with Dr. Fisher, of Hoboken. It was 
agreed that the patient be put to bed. Two leeches were applied to the mastoid- 
The hot douche was ordered to be used every two hours, and poultices were applied 
in front and behind the auricle. The patient began to be more comfortable at 
once. The drum-head perforated spontaneously on the third day. On the 
fourth day he was up, with no pain except at long intervals. In eleven days the 
drum -head had healed, and in twenty days the patient was practically well 
(H. D., fg), and he left town for the country. 

Case II. — Periostitis of Mastoid occurring during an Exacerbation in a Case of 

Chronic Suppuration of both Middle Ears — Recovery without Incision. — J. L. S , 

aged twenty-six. Farmer. February 21, 1883. Ten years ago he had the small- 
pox, which left him somewhat hard of hearing. Five years ago he had a severe 
cold, which very much increased the trouble. During January of this year, he 
had the measles, with severe pain in both ears, and a purulent discharge from 
the left. There was also a slight swelling of each mastoid, but it disappeared 
in about four days. One week ago this swelling returned. Each mastoid process 
is swelled and tender. Both drum-heads are perforated, but neither discharges 
freely. No aerial conduction in either ear. The patient was seen at my office, 
but he was advised to go to the hospital, which he did. He was then put to 
bed, two leeches were applied to each mastoid, and the hot douche was used 
often. The next day the tenderness of the mastoid was markedly diminished. 
The poultices and hot douche were continued, and in eleven days he was free 
from all pain and tenderness about the ears. 

These cases illustrate very well, how with circumspection, we 
may sometimes substitute leeches and poultices, for Wilde's in- 
cision and poultices. 

The two first of the following cases are from the notes of Dr. 
David Webster, when he was House Surgeon in the Brooklyn 
Eye and Ear Hospital, where they were under my care, and are 

SJi 



498 MASTOID PERIOSTITIS — CASES. 

striking evidences of the prompt relief afforded by timely inter- 
ference : 

Case III. — Chronic Suppurative Otitis Media — Cessation of Discharge — ALastoid 

Periostitis — Incision — Recovery. — Eliza N , aged eighteen, had a discharge of 

pus from the right ear for two months. The discharge suddenly ceased, and the 
patient was attacked with severe pain and swelling over the mastoid, which grew 
worse and worse for several days, and caused her to visit the hospital. Dr. 
Eoosa diagnosticated mastoid periostitis, and at once (May 10, 1869) made a free 
incision down to the bone. No pus was found, but there was free hemorrhage, 
which was encouraged by the use of warm water. The membrana tympani was 
found to be removed by suppuration, but there was a slight discharge from the 
canal. A tent was placed in the wound and a poultice applied over it. 

May 11th. — Patient has had no pain and has slei;)t well. The tent was re- 
applied and the poultice continued. 

May 16th. — The swelling of the mastoid is gone. There has been at no time 
a discharge of pus from the incision, but there was a copious one from the 
meatus. The patient was very pale when first seen, but the administration of 
iron and the cessation of pain have restored the normal condition. She has not 
since returned to the hospital. 

Case IV. — Chronic Suppurative Otitis Media — Mastoid Periostitis and Caries — 

Incision— Recovery. — Margaret O , aged forty-eight, came to the hospital 

June 21, 1869. Three months previously she had variola, and in the third week 
of that disease a purulent discharge began from the left ear. This discharge 
ceased, when, a week and a half ago, great pain, preventing sleep, set in. There 
was found to be considerable swelling and pumness above the ear, with tender- 
ness behind it, but no swelling. There was great oedema of the eyelids, and the 
patient seemed to be in great agony. The auditory canal was swelled, but 
scarcely any pus was found in it. Dr. Eoosa made incisions down to the bone 
above and behind the ear ; from the latter pus escaped, and a probe passed in a 
direction slightly upward, forward, and downward into the mastoid cells. The 
surface of bone about this opening was roughened. The same treatment as in 
the former case was prescribed. Hydrate chloral, gr. xv., was given at bed-time. 
Dr. Webster saw the patient the next day, when the pain had entirely ceased. 

June 28th. — No pain or tenderness. Politzer's method of inflation was prac- 
tised, and the warm douche used. 

July 12th. — A minute opening about a quarter of an inch from the attachment 
of the auricle still exists. The probe passes upward and forward into a super- 
ficial opening in the bone. No swelling, pain, or tenderness about the ear. The 
membrana tympani has healed. Hears the watch 6". 

Case V. — Chronic Suppurative Otitis Media — Mastoid Periostitis — Incision — 

Recovery. — William G , aged thirty, came to the Manhattan Eye and Ear 

Hospital, June 13, 1870. In December, 1869, he first experienced a sharp pain 
in the left ear, which was most severe at night. This pain continued for two 
months, at the end of which time a discharge occurred from the ear, which has 
continued more or less until now. Two months later the mastoid process became 
swelled and tender, and it was opened and poulticed by a physician. A great 
quantity of pus, as the patient says, was discharged, and the pain, which had 



MASTOID PERIOSTITIS— CASES. 499 

been severe, was relieved. About four weeks after this the pain in the ear again 
occurred, and the patient presented himself at the hospital. He presented the 
appearance of a great sufferer ; he was pale and haggard ; his hands were trem- 
ulous, and his countenance was anxious. He complained of great pain, referred 
to the depth of the ear and to the head. The mastoid process was red and hot, 
but not swelled or tender. The auditory canal was exceedingly sensitive. The 
membrana tympani had been removed by suppuration, and there was a thin 
coating of pus on the floor of the cavity of the tympanum. Air was forced into 
the middle ear by Politzer's method, and leeches were applied to the tragus and 
mastoid. On the next day warm water was frequently instilled. 

June 14th. — The pain in the ear has decreased, but there is more redness of 
the mastoid. Leeches, to be followed by a poultice were ordered. I did not 
see the patient after his second visit, in consequence of my absence from town, 
until the 20th, when I found fluctuation in front of the meatus, as well as great 
tenderness over the mastoid, with an increase of the constitutional symptoms. 
The patient was then admitted as an in-patient, and having given him a dose of 
whiskey on account of his very shattered condition, I proceeded to make free in- 
cisions down to the bone in front of and behind the ear. The bone was not 
denuded or roughened. A tent was inserted and a poultice, the latter to be 
renewed every three hours. The patient slept well that night for the first time 
in some weeks, taking a dose of fifteen grains of hydrate of chloral. 

June 28th. — The patient has since been free from pain. The incisions have 
nearly healed. There is a slight discharge of pus from the auditory canal. He 
hears a watch when it is laid upon the ear. His general condition is now very 
good, and he is discharged at his own request. 

It is somewhat remarkable that this patient experienced so 
many painful symptoms of mastoid disease for so long a time, 
and yet escaped without disease of the bone. His affection was 
never more than a disease of the lining membrane, with some 
periostitis, while in a case hereafter to be detailed, of much less 
severity, death of the bone occurred, and meningitis, with a 
fatal result, supervened. I now thiuk that a free incision should 
have been made over the mastoid when I first saw the patient, 
although there was then only some redness of the process and 
no tenderness, the pain being referred to the depth of the ear. 
In the light of my present experience, in all cases where there 
is deep-seated pain referred to the tympanum, which is not at 
once, that is to say, in a few hours, relieved by leeching, poul- 
tices, and the warm douche, even if the mastoid cells do not 
seem to be involved, I should consider myself as giving the pa- 
tient the benefit of a doubt by such a depletion as a free incision 
will afford. 

Case VI. — Chronic Suppurative Otitic Media of Year/ standing — Exacerbation 

— Mastoid Abscess— Incision — Recovery. — Gracie T> , aged thirteen, April 25, 

L872, I was summoned to Newburgh, by Dr. S. Ely. to see a case in consultation, 
which Dr. E. justly regarded as urgent. The patient was a healthy girl, who 



500 CARIES AND ABSCESS OF MASTOID. 

had had a discharge from her left ear for years, and who for the past few weeks 
suffered from an exacerbation of the disease, with acnte symptoms. Dr. Ely 
had observed that the mastoid process had become red, and swelled, and tender, 
within the last few days. We found the patient in bed, and evidently in great 
suffering, with considerable constitutional disturbance, hot skin, and frequent 
pulse. The neck was very much swollen, as was the whole integument of the 
mastoid. There was a profuse discharge of pus from the ear. On consultation 
it was agreed that an opening down to the periosteum should be made at once, 
which I proceeded to do, the patient being under the influence of ether. The 
opening was surprisingly deep, so that the knife passed through three-quarters 
of an inch of tissue befo.e the bone was reached. Pus escaped quite freely. 
The wound and the ear were syringed with lukewarm water, and an examination 
made for a fistula, but none was found. The bone was denuded of periosteum. 
The membrana tympani had been long since removed by suppuration. The pa- 
tient had a fair night, sleeping without an anodyne, and rapidly recovered after 
the opening had been made. A poultice was applied for a short time, and then 
the opening was allowed to heal. The ear was treated in the usual manner in 
cases of chronic suppuration. 

June 19, 1872. — The patient came to town to visit me. On examination, the 
membrana tympani was found to be removed by ulceration, and a small amount 
of pus lay in the tympanic cavity. The cicatrix on the mastoid is one inch long 
and one-half inch from the auricle. The patient states that the wound healed 
in about one week after it was made. 

CARIES AND ABSCESS OF THE MASTOID. 

Caries and abscess of the mastoid, result from an extension 
of the inflammatory process that has been described under the 
head of periostitis. The inflammatory process advances to sup- 
puration. Sometimes, and perhaps in the greater number of 
cases, the suppuration is not extensive and finds an outlet in a 
narrow fistula. This form is, of course, more dangerous than 
mere periostitis ; and yet cases of caries and necrosis are some- 
times relieved at the cost of much unnecessary suffering to the 
patient, by Nature's slow process of casting out diseased bone. 

An argument for temporizing with an undoubted case of 
suppuration within the mastoid cells, has sometimes been de- 
duced from this tedious manner in which Nature sometimes 
relieves a case without inducing a fatal result. But every sur- 
geon should certainly endeavor to spare his patient the discom- 
fort and danger of protracted suppuration, by carrying out the 
rules of his art, which demand an early, free, and deep incision 
whenever pus is to be found. 

After the detailed account that has been given of the symp- 
toms of mastoid periostitis, it is perhaps unnecessary to dwell 
at length upon the clinical features of caries and abscess. It is, 
moreover, oftentimes impossible to draw the line between a case 
of periostitis and one of caries. 



CARIES ATCD ABSCESS OF MASTOID. 501 

In many cases the symptoms of caries of the mastoid do not 
differ essentially from those of mastoid periostitis. There is 
the same redness, tenderness, and swelling of the process, at- 
tended by deeply seated and intense pain. In others, how- 
ever, the redness, tenderness, and swelling are entirely absent, 
while the pain referred to the depth of the ear, will be the only 
marked symptom. This pain is not relieved by leeches, and 
anodynes will only veil the symptoms for a brief period. Usu- 
ally, however, even in the insidious cases, tenderness will be 
shown upon firm pressure on the part. Yet the surgeon may 
cut down upon a bone to find it diseased, when he had not been 
previously able to positively diagnosticate this state of things. 
It may be said, however, in general terms, that any deep-seated 
pain referred to the mastoid or its region, occurring in the 
course of an inflammation of the ear, should be looked upon 
with suspicion, even if there be no redness, tenderness, or swell- 
ing of the process itself. 

The auditory canal is often involved in cases of caries of the 
mastoid. A fistulous opening is sometimes found leading from 
this part into the mastoid cells, in which case granulations are 
usually found in the canal. The presence of granulations in the 
canal should lead us to examine the part very carefully to see 
if a fistula may not be found. As will be seen by reference to 
page 512, dead bone may sometimes be removed through the 
canal. A clinical fact of some importance in the diagnosis of 
mastoid disease, is the one that the chronic or acute suppura- 
tive process in the middle ear, is often very much less violent, 
or entirely checked at the time of the outbreak of the periostitis. 
This fact applies to both forms of the disease. Yet it is a mis- 
take to suppose that mastoid periostitis, or caries, may not occur 
while a free discharge of pus is taking place from the ear. 

Treatment. — The first step in the treatment of a case of sup- 
posed caries of the mastoid, is to divide the tissues over the 
process down to the bone, as was recommended for cases of 
mastoid periostitis. If a fistula be found, it will be simply ne- 
cessary to enlarge this, so as to give a free exit to the pus. If 
the bone be very soft, a stiff probe will sometimes be sufficient. 
but usually a small drill will be required. If there be no fistula. 
and we have decided that dead bone is probably beneath the 
outer table, a small trephine may be used, and the process 
opened — the periosteum being, of course, first dissected up. The 
trephine should be worked in a direction inward, forward, and 
upward. There can be no positive directions given as to the 
depth to which the instrument should go. 



502 



TKEPHINING- THE MASTOID. 



Schwartze says, "Never go deeper than 25 mm." Buck says, 
"It is better, I believe, to place the extreme limit of depth at 
20 mm., or about three-fourths of an inch." ! 

By reference to the anatomy of the mastoid process (page 
236), it will be seen that the thickness of the outer layer of bone 
varies somewhat in different cases. The operation should go 
on very slowly, frequent pauses being made to see how deep the 
instrument has gone. It is impossible to say in a given case at 
what depth we shall reach the cells, or free spaces, and thus 
make an outlet for the pus. Dr. Agnew was obliged to go to the 
depth of five-eighths of an inch in one of his cases, and then 
found only sclerosed bone. Dr. D. C Ambrose, of this city, re- 
moved a piece one inch long from the mastoid process of a 
young woman of twenty years of age. The cell-structure will 
ordinarily be found at a depth of from one-sixth to one-fourth of 
an inch. In infants the outer shell of bone is so thin that true 
trephining will probably never be required ; but any firm in- 
strument will make the required opening. In case of an emer- 
gency, a surgeon has been known to use a common gimlet, to 
open the mastoid process. The lateral sinus will always be 

avoided by keeping the instrument as 
directed above. 

The after-treatment is the same as 
that of an operation for necrosis in 
other bones. The wound should be 
dressed from the bottom with a tent 
or with lint, and kept open for some 
time. The patient should be kept free 
from all noise and excitement, and 
very carefully watched until the fis- 
tula has healed, which may be for 
months. I think a long tent made of 
old and thin cotton cloth, much better 
than the silver or rubber drainage-tubes. The fistulous opening 
should be dressed at least once a day. 

In some cases — I have one such under observation, which 
was operated upon by Dr. E. T. Ely — the fistula cicatrizes 
throughout its course, but never closes. I have also seen a 
case, kindly sent me by Professor Sayre, where an opening 
made by a bullet also left a permanent opening without suppu- 
ration or other inflammation. The patient, who received the 
wound in the late civil war, wore a cover to the opening. 

Schwartze, who has had a large experience, uses a chisel and 




Fig. 107. — Schwartze's Chisels for 
Opening the Mastoid. 



Treatise on the Ear, p. 369. 



TREPHINING THE MASTOID— HISTORY. 503 

hammer for opening the mastoid. I have assisted Dr. Gruening 
in one operation in which he used this method, but I do not like 
it as well as the drill, or the small trephine. 

The skin should be well dissected up from the periosteum 
before the opening into the bone is made. During the after- 
treatment, it will often be necessary to trim up the edges of 
the external opening, that the pus may always have a free out- 
let and not burrow under the skin, Too much importance has 
been ascribed to this operation by some writers. It is after all 
a plain surgical operation, which no man with any considerable 
experience in general surgery, need hesitate about when it is 
indicated. 



HISTORY OF THE OPERATION FOR OPENING THE MASTOID PROCESS. 

The following history of the operation of opening the mas- 
toid process, is essentially the same as that which I published 
in 1870. * It has been amplified in some places. It was the first 
complete account of this operation which appeared from the 
time of the publication of Lincke's works, when it had been vir- 
tually abandoned as a dangerous procedure, until its revival 
was rather timidly urged by Yon Troltsch. The revival when 
it occurred was the result of a few isolated operations by bold 
surgeons here and there, such as A. B. Crosby in America, 
James Hinton in England, Triquet and Follin in France, and 
Ludwig Mayer and Jacoby in Germany. These operators dis- 
carded tradition, and each for himself, decided that in the case 
before them, an attempt should be made to save life, by evacu- 
ating concealed pus, whose pressure threatened the integrity of 
the structure of the brain, or the quality of the blood. 

One of the most severe commentaries, upon the general in- 
competency that possessed the field of aural surgery for so long 
a time, is found in the fact, that this sound surgical procedure 
remained for so many years outside of the view of the profes- 
sion. 

It should also be said, that the teachings of Sir William 
Wilde, in Great Britain, and Alfred C. Post, in this country, in 
performing and recommending early, free, and deep incisions 
through the periosteum, in mastoid periostitis, assisted materi- 
ally to prepare the profession for the reinstatement of the opera- 
tion for opening the bone. 

1 Transactions of the American Otologioal Society. Medical Record. 1870. 



504 TEEPHINING THE MASTOID — HISTOEY. 

From a monograph on this subject by J. Arneman, 1 Professor 
in the University of Gottingen, we learn that Riolanus (in 1649, 
according to Adolph Murray 2 ), was the first author who inquired 
into the propriety of perforating the mastoid process in cases of 
occlusion of the Eustachian tube, for the purpose of removing, 
by injections through the opening, morbid secretions in the mas- 
toid cells and cavity of the tympanum. Rollfink, afterward, in 
an anatomical dissertation, published at Jena in 1656, also advo- 
cated the operation. J. L. Petit (1750), according to Yon Troltsch, 3 
was the first who actually performed the operation, which he did 
by means of a gouge and hammer. 

Then we come to Valsalva's case, published nearly a hundred 
years after the suggestion of RiolaAius, which has been claimed 
by all the authors as a case of perforation of the mastoid, and in- 
jection through it of the middle ear. One writer (Yon Troltsch) 
states that an otorrhoea was thus cured by Valsalva. I have 
examined the original passage in order to verify this claim made 
for Valsalva, and I find that there is no such claim by Valsalva 
himself. He simply states that he injected a fistula existing in 
this part, in the case of a nobleman ; with what result he does 
not say. The following is the side-note to the passage : 4 " Obser- 
vatio ulceris ad processum mamillarem, per quod injecta, statim 
in oris cavitatem, licet undequaque illcesam transmittebantur '." 
The passage itself is as follows : "Adeoque mitto prolixius con- 
firmare per quondam meam in vivo homine observationem, de 
nobili scilicet viro, ulcere ad processum mamillarem, cum hujus 
carie labor ante in quod quce injiciebantur, illico ad fauces per- 
veniebant adeoque a tympano, quo per illius processus sinuosi- 
tates ascenclebant, per tubam certe derivebantur,^ etc. 

This passage may be translated as follows. After speaking 
of the Eustachian tube as a passage to the pharynx, Valsalva 
says : "I beg to confirm what I have said, by an observation 
made on the living subject, a nobleman, who was affected with 
caries of the mastoid process. The fluids that were injected into 
this ulcer passed through the sinuosities of the mastoid process 
into the tympanum, and thence through the tube to the fauces." 

Valsalva is here demonstrating the function of the Eusta- 
chian tube. He makes no claim to have perforated the mastoid, 
but he simply asserts that he has injected a fistula in the mas- 
toid, and that the fluid thus injected passed into the mouth. I 
cannot find any evidence in the passage or the context that his 



1 Bemerkungen iiber die Durchbohrung des Processus Mastoideus in gewissen Fallen 
der Taubheit. Gottingen, 1792. 2 Lineke's Sarcmlung, IV., p. 23. 

3 Lebrbuch. Funfte Aufgabe, p. 454. 4 Tractatus de aure Humana, 1742, p. 89. 



TREPHINING THE MASTOID — HISTOEY. 505 

patient was cured of an obstinate otorrhcea, as asserted by Von 
Troltsch, so that I think Valsalva must be left out, so far as any 
evidence from this passage goes, in the enumeration of those 
who have recommended or performed the operation of which we 
are speaking. 

The surgeon to whom we are indebted for having fairly estab- 
lished opening of the mastoid as a legitimate surgical procedure, 
is Jasser, 1 a regimental surgeon, who, in 1776, first performed it. 
His patient was a soldier, who had suffered for many years from 
suppuration and pain in the ears, which was not relieved by 
active but judicious antiphlogistic treatment. In this case there 
was an abscess of the mastoid, and death of the bone — and thus 
the operation was performed under indications which any good 
surgeon of the present day would accept as peremptory. Al- 
though Jasser's operation was a creditable one to its author, it 
has been misunderstood, and classed by Wilde in the list of the 
same operations performed with such indications as "obstinate 
deafness." 

Arneman, in the pamphlet before alluded to, details five other 
cases, from Fielitz, in which the operation was performed, and 
claims that in only one was there a bad result, and then death 
ensued. He admits, however, that it may be performed without 
avail. The bad result occurred in the case of Berger, a Danish 
surgeon, who caused it to be performed on himself, and died of 
meningitis induced by the operation. Berger had suffered for 
years from very great vertigo and noise in the ears, and gradu- 
ally lost his hearing power. He got no relief from the ordinary 
means of treatment, and his malady, which placed him out of 
the society of his friends, troubled him very much. He finally 
determined to have the operation of trephining the mastoid per- 
formed, in order to inject the parts and remove the hardened 
secretion. Berger evidently suffered from what we should now 
term chronic proliferous inflammation of the middle ear ; and 
viewed in the light of our present knowledge, there was no 
proper indication for the operation of trephining the mastoid. 
Dr. Kolpin perforated the process to the depth of three lines. 
The incision does not seem to have reached the cells, for an 
injection made in the opening did not pass into the throat. On 
the day after the operation a chill occurred. These chills con- 
tinued to recur, and on the twelfth day Dr. Berger died. Adhe- 
sions of the dura mater to the skull were found, and effusion of 
a transparent gelatinous fluid between the arachnoid and pia 
mater, as well as over the whole surface of the cerebrum and 
cerebellum. 

1 Lincke's Sammlung, Bd. IV., p. 105. 



506 TKEPHINING THE MASTOID — IIISTOEY. 

The second case detailed by Arneman, has no more accurate 
statement as to the pathological condition of the ears of the pa- 
tient upon whom it was performed, than that he was wholly 
deaf in both ears. The operation did no good, but caused tem- 
porary blindness and faintness. In the third case there is also 
no account of the cause of the deafness ; the result was an im- 
provement of the impaired hearing as long as the wound was 
kept open. The opening was maintained by means of a leaden 
probe until cicatrization occurred. 

The fourth case was that of an old lady, who had lost her 
hearing from a quartan fever. She had noise in both ears. The 
process was perforated, and injections of lukewarm water, 
which passed out of the nostrils, were made. After the injec- 
tions had been made for four days there was a complete resto- 
ration of the hearing (sic), while the openings closed readily. 

The fifth case was one of chronic suppuration in the ear, 
with acute exacerbations. The result was a cure, after injec- 
tions for twelve days. 

These statements must of course be taken with some allow- 
ance, inasmuch as with the exception of two cases — the first 
and the last — there is no exact knowledge of the disease caus- 
ing the symptoms of deafness and tinnitus. But even these 
show that perforation of the mastoid is not a dangerous proced- 
ure, and that when performed under such indications as those 
in Jasser's case, it is not only a very simple, but a very bene- 
ficial operation. 

In Frank's treatise on the ear several cases are alluded to ; 
but here also the indications which direct their performance are 
wanting, and they are consequently useless as guides to the 
surgeon. 

A surgeon, named Weber, in 1825, 2 made an opening into 
the mastoid in a case of caries of the bone, but evidently with 
great anxiety, lest what he was about to undertake might not 
be good surgery, although his patient had symptoms which 
would not allow us to hesitate for a moment. He used a t:\ 
and went about three lines before he came to the cells. r J.*e 
patient recovered. 

Arneman, in a style of surgical writing which has now, 
happily for us with our more accurate knowledge, passed away, 
lays down the following indications for the performance of the 
operation. They are inserted here in order that the distrust 
with which surgeons have looked upon interference with the 
mastoid process in aural disease, may be accounted for. 

1 Lincke's Sammlung, Bd. IV. , p. 90. 



TREPHINING THE MASTOID— HISTORY. 507 

I. In any case of absolute deafness, or in any case where the impairment of 
hearing is constantly increasing, and for which all other remedies have been 
used without effect. 

II. When, in case of an ulcer or suppuration of the ear, the morbid material 
has become collected in the cells of the mastoid, or the cells have become 
carious. (This is certainly a good indication, and the one upon which Jasser 
acted.) 

III. If the normal mucous secretion has become hardened or collected in 
excessive quantity. 

IV. In cases where pain and noise, which would finally destroy the hearing, 
have existed in the ear for a very long time. 

V. In cases of stoppage of the Eustachian tube not remedied by injections. 

The simple operation of creating an external opening for 
retained pus, and thus preventing its passage to the brain and 
into the circulation, was so distorted from its proper applica- 
tion, by the improper indications for its performance, that the 
leading writers seem to have been in as great a state of be- 
wilderment about it as were the English and American sur- 
geons, until a few years since, in regard to the use of the Eus- 
tachian catheter. The text-books either mention it to condemn 
it, or in such a way as to plainly show that they do not realize 
the true indications for its performance. 

So valuable a work as that of Wilde, for example, confounds 
such an operation as that performed by Jasser with the others 
quoted by Arneman, which were undertaken because the first 
operation had been successful, and without any regard to the 
condition of the ear, but for the relief of a symptom — deaf- 
ness. 

In the general advance of our exact knowledge of diseases 
of the ear, the merits of the operation of perforating the mas- 
toid were again discussed, and it has now been replaced where 
Jasser first placed it, on a sound basis. Von Troltsch, in 1861, 
reported a case of acute suppuration in the middle ear, with 
perforation of the membrana tympani, in which he opened the 
mastoid with a probe, some days after he had made Wilde's in- 
cision with only partial relief. 

In such disrepute was this operation at that time, because 
of the unhappy fate of Berger, who caused it to be performed 
with no good indications, that Yon Troltsch confesses that lie 
would have hesitated to undertake this simple operation with 
any but the instrument which he employed. The case was 
a successful one. Eight cases are reported by Troltsch : that 
of Petit is considered the first, and Jasser's the second : but 
Valsalva's injection of a fistula already existing is considered 
as an operation. 



508 -• TREPHINING THE MASTOID — HISTORY. 

In 1863 ' Hermann Schwartze reported the case of a child of 
one and a quarter years old, who had coxitis and also suppura- 
tion of the ear. The mastoid was swelled and fluctuating. 
Wilde's incision was made and pus evacuated. Some days 
after, an examination with a probe detected rough exposed 
bone, which was easily perforated. A teaspoonful of pus then 
escaped. The little patient died in six weeks from the time it 
was examined by Schwartze. It will be seen that this was 
very like the case of Von Troltsch. In both instances an opening 
was made into soft bone by a probe. To this day, most of the 
cases requiring opening of the mastoid, are of this character. 
But surgeons are not now so timid about the use of an instru- 
ment better adapted than a probe, for opening bone. In Turn- 
bull's case 2 Buck states that he can find no evidence that any 
operation was performed upon the bone, beyond the introduction 
of a buttoned probe into a small fistulous opening. This he also 
says of Troltsch's case. But scarcely any of the operations 
from the time of Jasser to Mayer, are cases of a deliberate open- 
ing of the bone, but rather the completion with a probe of open- 
ings that nature had begun to make. We now come, however, 
to a time, when the operation of opening the bone, is to be for- 
mally performed and recommended. In 1864, Ludwig Mayer 
published a case in which he opened the mastoid. He appears 
to be the first German surgeon who performed the operation, 
after Troltsch's suggestion. In 1868, L. Jacoby 3 began to write 
upon this subject and to publish cases of his own. He reported 
five cases at various times, and in 1870 he recommended a spe- 
cial trephine for opening the bone. Jacoby also gave a table of 
the operations previously performed. Pagenstecher, 4 of Elber- 
feld, reported four cases about this time, as does Flaitz, 5 in 1867, 
a surgeon in the Baden army. Triquet's cases are in the Gaz. 
desHop. of October 27, 1861. Three cases are reported by Kessel 
in 1869 6 as having been operated upon in 1869. In the same 
year 7 Koppe and Schwartze, report a case of reflex epilepsy 
with caries of the temporal bone cured by an operative perfora- 
tion of the mastoid process. The operation was performed on 
August 2, 1869. An account of my first case, was read before the 
American Ophthalmological Society in 1870, and published in 
the Medical Record in July of that year. It was accompanied 
by the historical account here again published. 

1 Praktisclie Beitrage zur Ohrenheilkunde, 1864, p. 37. 

2 Treatise on the Ear, by Turnbull, p. 194. 

3 Archiv ftir Ohrenheilkunde, Bd. IV. 

4 Ibid , Bd. L, p. 359. 5 Loc. cit., Bd. IV., p. 57. 
6 Archiv fur Ohrenheilkunde, Bd. IV., p. 57. 7 Loc. cit., Bd. V., p. 93. 



TREPHINING THE MASTOID— HISTORY. 509 

Agnew ' also published a case in 1870, in which he trephined 
the mastoid. This was one of the cases in which Crosby had 
used a gimlet, in 1864. In 1873, 2 at a meeting of the New York 
Pathological Society, in a discussion upon the subject, opened 
by Dr. N'oyes, A. B. Crosby said that he had perforated the mas- 
toid three times with a gimlet. The first case was operated 
upon in 18G4, that of a lady, and was one of acute inflammation 
of the middle ear which had lasted about a month. There was 
"a slight discharge from the ear, dizziness, headache, and some 
disturbance of vision." Eelief resulted from the operation. Id 
the second case there was marked inflammation of the mastoid 
cells, and when the opening was made with the gimlet, "the 
pus jetted two inches from the wound/' The patient recovered 
rapidly. Crosby's third case was that of a medical man, who 
had a severe otitis media, with vertigo. His pulse was rapid, 
tongue dry, and there were other symptoms pointing toward 
pyaemia. The mastoid was perforated, the gimlet again being 
used. Pus appeared in twenty-four hours, and ultimately the 
patient recovered. 

A. H. Buck 3 published a paper upon the subject with a table 
of thirty-five cases, in 1873. The first case in his table is that of 
Jasser. The last are six cases from his own practice. 

Ludwig Mayer, 4 in reporting his case, said that it was the 
eleventh on record. The patient was a woman of about twenty 
years of age. She died nine days after, and no post-mortem 
was allowed. In 1871-72, Jacoby 5 reported two additional cases 
of perforation of the mastoid, with an extended commentary upon 
the cases. In 1872, five cases are reported from Professor Volk- 
man's clinic, in Halle, in an inaugural thesis by M. Schede. The 
diseased bone was removed by a sharp-edged spoon or curette. 
In the number of the Archives of Otology published in Germany 
on June 6, 1873, p. 157, Schwartze and Eysell began with a his- 
torical account, a series of publications upon the perforation of 
the mastoid which have been continued, at some intervals, by 
Schwartze, up to this day. 

The historical account which was given in the first edi- 
tion of this book, and which is here reproduced, together with 
my first case, preceded this publication of Schwartze and Eysell 
by more than three years. I have thus given the history of the 
revival of this operation in some detail, in order to bring out the 



1 Transactions of the American Otological Society, 

8 Medical Record, vol. iv., p, 20. 

8 Archives of Ophthalmology and Otology, vol. Hi. , p 173. 

4 Archiv fur Ohrenheilkunde, Bd. I., p, 887, 

6 Loc. cit, Bd. V., p. 93. 



510 TREPHINING THE MASTOID. 

truth that has not always received recognition, that America, 
has had her full share in the establishment of perforation of the 
mastoid upon a scientific basis. 

In spite of this apparently general revival and endorsement 
of the operation, at the meeting of the American Otological 
Society, in 1883, the subject was discussed on the part of some 
authorities, as if the operation were still a questionable and un- 
necessary one. For example, Strawbridge stated that he had 
seen over 4000 cases of purulent middle-ear disease within twelve 
years, and yet he had not trephined a single mastoid, nor had 
he seen a death, except in a child of six months old, that died in 
a few hours after he first saw the case. Knapp, took decided 
ground in favor of the operation in appropriate cases, and said 
that he had seen three cases in which death occurred, where, 
as he believed, opening the mastoid would have prevented 
a fatal issue. Sexton said, that, although he had seen a large 
number of aural cases, he had seen but very few where he 
thought it necessary to make a perforation, without some evi- 
dence aside from pain existing in the mastoid. He also al- 
luded to the important control which he thought sulphide of 
calcium exercised over inflammatory processes. Kipp had seen 
quite a number of fatal cases of otitis media, in which the 
post-mortem had shown that the mastoid cells were filled with 
pus, which had given rise to cerebral abscess. C. H. Burnett 
thought we were not likely to make a mistake upon the side of 
the operation. In a fatal case, which he reported, he thought 
if his patient had been operated upon a year before, that he 
would not have died of pyaemia. Gruening said that surgery 
has established that wherever there is a focus of purulent dis- 
charge it should be removed. This (removal of the focus) is a 
life-saving operation, and should be done under all circumstances. 
He had performed the operation at least sixty times. In twenty- 
eight cases he had found pus. In two cases he did not find pus 
at the time of the operation, but on the following day profuse 
suppuration existed and the patient was immediately relieved. 

It is hardly necessary for me to say, that I believe that the 
revival of the operation of opening the mastoid process, has 
saved many lives. Not a year of my practice has passed since 
I first performed this operation, but that I have found it neces- 
sary to repeat it in several cases. It is true, that we shall seldom 
need to open a mastoid if an experienced practitioner sees a case 
of acute aural disease early in its course. It is an operation for 
neglected cases, where suppuration has been allowed to advance 
from the tympanum in consequence of not having a free outlet 
through the drum-head. But purulent inflammation of the mas- 



INDICATIONS FOR TREPHINING:. 511 

toid, may occur in acute cases, that have been thoroughly treated 
by leeches, poultices, rest, and so forth, from their start. I do 
not consider the operation at all a dangerous one. With those 
who are in favor of giving an early and free discharge to pus 
whenever it is to be found, I would rather err on the side of an 
unnecessary operation, than to lose one patient from neglecting 
a surgical principle, about which, as Dr. Gruening remarked 
in the discussion from which I have just quoted, there can be 
no argument. So far as propositions in regard to operations 
upon the mastoid can be formulated, I should say : 

I. The integument and periosteum of the mastoid process 
should be freely divided in all cases, when there is great pain, 
tenderness, and swelling in this part. 

II. Such an incision should also be made, whenever severe 
pain, referred to the middle ear, constantly exists, and which is 
not even temporarily relieved by the use of leeches, poultices, 
the warm douche, and so forth. 

III. The bone should be thoroughly examined by the aid of 
such an incision, whenever we have good ground for suspecting 
that the bone is diseased or pus is retained in this part. 

IV. The mastoid process should be perforated after such an 
incision, whenever the bone is found softened, or if a fistulous 
opening is discovered, this should be enlarged. It should also 
be perforated, when the suppuration of the middle ear involves 
the mastoid cells or antrum to such an extent, that thorough 
drainage cannot be secured through the membrana tympani or 
external auditory canal. 

I would not lead my readers to think that I consider the open- 
ing of the mastoid process as a trivial procedure, the indications 
for which, need not be carefully considered before it is under- 
taken. 

Yet hesitation, when the way is plain, or when the chances 
are largely on the side of the necessity of the removal of pus. 
cannot be too sternly condemned. No drug has yet been discov- 
ered, which can be substituted for the scalpel, or trephine, when 
pus has actually formed in the mastoid cells. I wish, however. 
to repeat what I have said before on the subject of surgical 
operations. I am in full accord with the great English surgeon, 
Sir James Paget, who, in his admirable lectures, expresses many 
times his hesitation to perform any surgical operation, however 
trivial, that is not absolutely required. We have no right, I 
think, to perform operations to clear up doubtful diagnoses ; if 
in case the operation proves to have been unnecessary, the pa- 
tient will be decidedly the worse for it. If we put ourselves in 
the place of our patients, what we may regard as a trifling thing. 



512 TREPHINING THE MASTOID — CASES. 

"a mere cut," will not be so esteemed. A mere cut, when un- 
necessary, may have the most serious consequences, and all the 
history and symptoms should be carefully weighed before even 
that is undertaken. Such care will never prevent prompt, rapid, 
and thorough surgical interference when demanded. 

In teaching medical students, I have always found them, 
when fully awakened to the dangers of neglecting certain dis- 
eases, to be more apt to do too much, than too little, especially 
with the knife and active drugs. It is possible also that the cry- 
ing ignorance and neglect of the previous decades in regard to 
the treatment of aural disease, has had a tendency to cause us 
who see many of the affections of the ear, to lean toward the 
side of surgical operations upon the drum-head and mastoid. 
This is a leaning no less dangerous to the cure of some cases, 
than was the steering toward Scylla or Charybdis to the safe 
navigation of ancient mariners. 



CASES. 

It would be easy to insert very many cases of trephination of 
the mastoid, from my case-books, and from the great numbers 
that are now to be found in the literature of otology, but in ad- 
herence to the plan of this work, a few are selected which will 
clearly exhibit the symptoms of caries of the mastoid, and the 
clinical facts of those cases for which perforation of the process 
is performed. 

Case I. — Otitis Suppurativa Media — Caries of Mastoid — Incision through Peri- 
osteum — Removal of Sequestrum through External Auditory Canal — Recovery. — 
This was under my c-are at the Manhattan Eve and Ear Hospital, and has already 
been reported by Dr. C. I. Pardee, 1 but chiefly with reference to its being a case 
of otitis media, caused by the use of the nasal douche. I saw this j^atient, who 
was a man of about thirty-rive years of age, soon after the inflammation of the 
ears had occurred, which was about nine months before he presented himself at 
the hospital in October, 1869. He was then suffering from a suppurative inflam- 
mation of the middle ear, but the amount of pus discharged through the perfora- 
tion in the membrana tympani was slight. There was considerable swelling of 
the mucous membrane of the cavity of the tympanum, and the hearing was 
greatly impaired. He could not hear a watch at all. He was under my care for 
this suppuration of the ears for eight weeks, when he disappeared, and I next 
saw him, as just stated, some nine months after, at the hospital, when I found 
his condition had become worse, and that it was alarming. He complained 
greatly of pain in the head, which prevented him from pursuing his avocation, 
which was that of a plumber. The auditory canal of the left side was filled 
with granulations, the mastoid process was red, tender, and painful. Just in 

1 New York Medical Gazette, vol. vi., No. 23. 



TREPHINING THE MASTOID — CASES. 513 

front of the meatus there was an abscess, and a small fistulous opening just above 
the same part. The hearing on that side, as tested by the watch and voice, was 
completely gone. On the other side, the ear was in substantially the same con- 
dition as when I first saw him. 

I immediately made incisions down to the bone, rather against the patient's 
will, just behind, above, and in front of the attachment of the auricle. I found 
no dead or exposed bone, but quite a large amount of pus was evacuated. The 
patient immediately began to improve. In a few days Dr. Pardee removed a 
piece of the mastoid structure through the auditory canal, the pain in the head 
disappeared, the suppuration from the mastoid ceased, the granulations were 
removed from the canal, and the patient resumed his occupation. 

The notes of the following case, except so far as they relate 
to matters observed by myself, were furnished me by Dr. Hub- 
bard, of Bridgeport, through whom I saw the patient. 

Case II. — Sub-acute Aural Catarrh — Membrana Tympani intact — Suppuration 
in Mastoid Cells — Opening of Mastoid Process — Death. — Dr. Hubbard was con- 
sulted in December, 1869, as he wrote me, " by W. E. S , aged thirty- eight, by 

profession a mechanic, with good physical development and unexceptionable 
habits, on account of a severe influenza, from which he was suffering, and which 
was at that time epidemic in this city (Bridgeport). His mother and one sister, 
I have reason to believe, died of tubercular inflammation. The attack of influenza 
was characterized by severe irritation of the whole respiratory system, with 
marked impairment of the special senses of taste and smell. The auditory appa- 
ratus was not at first, however, specially implicated. I prescribed for his ' cold ' 
several times during the acute stage, as an office patient. But he at those visits 
made no mention of any trouble about his ears. Later he reported that he had 
lost his cough, but complained of catarrh of the fauces and nasal passages, for 
which I prescribed the nasal douche, and gargles made stimulant and astringent 
by alum, chlorate of potash, chloride of sodium, tannin, etc. To the use of these 
he ascribed considerable improvement. I then lost sight of him until about the 
first of April, 1870, when he consulted me on account of an annoying tinnitus 
affecting only the right ear. At the same time he reported that he had occa- 
sionally, for several weeks immediately preceding, suffered moderate hemicrania 
of the affected side. Inspection showed marked enlargement of the mastoid 
process, which he declared had been at no time the seat of pain, and yielded no 
suffering under firm pressure. Specular examination showed a moderate degree 
of congestion of the membrana tympani, and by Politzer's method the Eusta- 
chian passage was found to be pervious. The middle ear was occasionally in- 
flated, however, and warm- water injections to the meatus externus ordered daily 
at bedtime, and a blister directed to be applied over the mastoid process. 
Under this course the apparent congestion of the membrana tympani dis- 
appeared, but the tinnitus was in no degree diminished. At this stage of the 
case I advised him to consult Professor Boosa, and he advised me to renew the 
blister to the mastoid region, also to apply a leech to the tragus, and repeat it 
after a stated interval, after which he requested to see him again." 

My notes, on seeing the patient, are : Hearing distance, right side. '1 . 
tested with a watch that should be heard 3' : membrana tympani opaque ; no 
light spot ; handle of malleus injected. A very feeble current of air passes 
33 



514 TREPHINING- THE MASTOID — CASES. 

into the Eustachian tube. Patient complains of an annoying buzzing sound 
in his ear. There is a slight want of symmetry in the mastoid, no pain re- 
ferred to it, no tenderness in any part of it ; no pain in the ear. Two leeches 
ordered to the tragus and a blister to the mastoid. One week later I again 
saw the patient ; the symptoms were the same. He had had some pain in the 
ear one night since his visit. I injected steam into the middle ear, and sug- 
gested that leeches be again applied. 

(I again copy Dr. Hubbard's notes.) 

" These measures were faithfully carried out, but with no good results. 
The time having come for another visit to Dr. Boosa, the patient called at my 
office, when examination revealed fluctuation at the summit of the mastoid 
process, indicating, however, a small quantity of fluid, and attended, as it 
seemed to me, with too little pain to be explained by the theory of a perios- 
titis. I thereupon advised him to postpone his visit to New York, and poul- 
tice the tumor for twenty-four hours, and then report again. At his next visit 
I found the swelling and fluctuation slightly increased, and I freely incised the 
integuments to the bone, liberating about half a drachm of thick, healthy- 
looking pus without disagreeable odor. I then probed the wound, expecting 
to find denuded bone, but I failed to detect a greater degree of roughness than 
is peculiar to that portion of the cranium. I advised him to keep the wound 
open and favor the discharge by poulticing. The discharge for the succeeding 
few days was little, but resulted in a marked diminution of the tinnitus and a 
corresponding sense of relief to the patient. He now failed to report to me 
for about a week, and meanwhile, from lack of attention, the incision healed, 
and when he presented himself again there was a reaccumulation of pus in 
much greater quantity than previously. This I evacuated, and found it of 
the same character as before. Thereafter the wound was kept open and the 
tinnitus ceased, and the patient declared to me and others that he was ' a new 
man.' From this time my regular attendance ceased until May 12, 1870, when 
I was recalled and obtained the following history : He had continued in his 
improved condition until the evening previous, which he was passing in social 
enjoyment with his family and a brother who was paying him a visit, and, when 
laughing violently at some burst of humor, he stopped suddenly and exclaimed : 
' There, I guess I have laughed too hard, for I have made my head ache.' No 
further reference was made to his suffering until he had retired to his room at 
bedtime, when he informed his wife that he was suffering from an intense frontal 
headache ; he also complained of rigors, and passed an uneasy, sleepless night. 

"May 13th.— I found the patient still suffering from pain through the fore- 
head and temples ; pulse 70, regular, and with steady rhythm ; tongue brawny, 
a thin white fur upon it ; intellect clear ; skin unusually open, and feeling like 
the third stage of a paroxysm of intermittent fever, which I confess I was dis- 
posed to consider it, inasmuch as he had previously suffered from that disease. 
I did not consider the symptoms sufficiently clear to indicate antiperiodic treat- 
ment, and I therefore temporized by giving the following palliative (a mixture 
of morph., aconite, and camphor- water) . 

"May 14th, a.m. — Found him no better. Skin still open; pulse 68, with 
slight unsteadiness of rhythm, coating still more inflammatory ; headache the 
same ; urine rather copious ; intellect in the morning clear, but once had re- 
quested an imaginary window-frame to be removed from his bed ; pupil un- 
affected, no intolerance of light or sound ; temper cheerful. I abandoned the 



TREPHINING THE MASTOID — CASES. 515 

malarial theory, and expressed myself to the friends as apprehensive of basilar 
meningitis, consecutive to sub-acute inflammation of the mastoid cells. Ordered 
an active cathartic, and 3 ss. bromide of potassium, combined with the iodide. 
p.m. — Visited him in consultation with my partner, Dr. D. H. Nash. No relief; 
on the contrary, an increase of the cerebral disturbances, occasionally delusions 
and illusions of mind, and mostly of the ludicrous sort ; pulse slow and some- 
what staggering ; no pain in the ear or its surroundings ; bowels had moved 
freely two or three times ; urine still copious ; has had no sleep. Continue the 
bromide of potassium mixture, apply large blister to the nape of the neck, and 
give gr. xx. hydrate of chloral, and repeat in four hours if necessary. 

"May 15th, a.m. — Had slept about two hours; general condition no better ; 
decidedly humorous in his behavior ; double vision, without apparent strabis- 
mus ; could not read ; pulse 60, more irregular ; had less pain in the head, or 
at least he said less about it. Continued same line of treatment, with addition 
of gr. ij. calomel once in four hours. Blister acted thoroughly, p.m. — Condi- 
tion little changed. Prognosis to family — fatal result, qualified by suggestion 
of possible relief from trephining mastoid process. 

"May 16th, a.m. — Patient worse; suggested the counsel of Dr. Eoosa ; 
treatment the same. Met him at 9 p.m., with Dr. Nash. Agreed to diagnosis 
of meningitis, witli probable origin from mastoid cells. Determined on free 
explorative incision upon the mastoid process, and use of trephine if develop- 
ments indicated it. Accordingly Dr. Eoosa made an incision one inch and a 
half long, parallel with the attachment of the auricle (about one-half inch pos- 
terior), down to the bone, permitting thorough examination with the finger as 
well as with the probe. This means, however, failed on the part of either of us 
to discover either necrosis or a denuded state of the bone. After a long search, 
and when the search and further procedure were about to be abandoned, the 
probe (in the hands of Dr. Hubbard. — B.)— Bowman's No. 1 — caught in a little 
depression, and by considerable ru'essure passed the external table of the cra- 
nium, into the interior of the mastoid portion of the temporal bone, to the depth 
of one and a half inch, without other resistance than that afforded by the ex- 
ternal table. The orifice was now enlarged sufficiently to favor the escape of 
any pus that might be in the depths of the bone, an opening three-eighths of 
an inch in diameter, but no great quantity of pus escaped (just a trace. — B.). 
Subsequent examination with the probe revealed a cavity of considerable size, 
caused by the breaking down of the mastoid cells. (The incision was carefully 
syringed with tepid water, and the opening plugged with lint. — B.) 

"May 17th. — I first observed dilatation of the pupils, with gradually in- 
creasing drowsiness, attended by delirium. This condition continued, with 
occasional aggravations, until the 19th, when the patient passed slowly into a 
state of profound coma, and he died without convulsions, at 2 o'clock a.m., May 
20th. No post-mortem examination could be obtained." 

I have only to add a few words to the history thus so graphically given by 
Dr. Hubbard. On the evening of the operation, or the third and last time I 
saw the patient, I examined the case as carefully as possible, and I found the 
membrana tympani intact and translucent, no congestion whatever. There was 
no bulging in any part of its surface. The patient, who recognized me per- 
fectly, and showed that his memory was unimpaired, heard my watch about six 
inches from the ear — a decided improvement upon the hearing power on the 
two occasions when I had previously seen him. There was absolutely no tender- 



516 TREPHINING THE MASTOID — CASES. 

ness in any part of the mastoid. Besides a very minute opening near the supe- 
rior boundary of the process, which was scabbed over, there seemed to me to 
be no abnormal appearance in this part, and I examined it veiy carefully. On 
probing this minute opening, which was the trace of Dr. Hubbard's incision of 
some weeks before, there was no escape of pus. 

So doubtful did the case seem to me, even with the history of the abscesses 
which had been opened, that I hardly expected that the free incision which I 
made would reveal anything abnormal. 

There are several points in this case which distinguish it from 
any that had then been reported. 

I. There never was a suppuration of the membrana tympani. 
A primary inflammation of the mastoid cells or their lining 
membrane, or of the periosteum in this region, is very rare, as 
is a middle ear inflammation in which the mastoid becomes in- 
volved, without suppuration in the cavity of the tympanum. I 
have seen one case, however, in which the use of the nasal 
douche caused an inflammation of the mastoid of one side, with- 
out suppuration in any part of the ear, while in the other sup- 
puration of the membrana tympani occurred. But the mastoid 
inflammation was quickly overcome by the use of leeches. This 
case was reported some time before the other cases of so-called 
primary inflammation of the mastoid, alluded to on page 492. 

II. Until the formation of the abscess, there were no marked 
symptoms indicating the true seat of the disease. The symp- 
toms were rather those of a chronic inflammation of the middle 
ear, that is to say, tinnitus, fulness, and occasionally slight pain. 
Certain it is, there was none of the agonizing, distracting pain 
of which patients with periostitis usually complain. 

III. The interval of apparent recovery after the evacuation 
of the pus. 

In reviewing the case, the conclusion seems to me inevitable 
that we had from the beginning to do with a sub-acute inflam- 
mation of the mastoid portion of the middle ear, and which 
smouldered until the blazing up in the abscess opened by Dr. 
Hubbard. The origin of this was, of course, the coryza, or cold 
in the head. It was perhaps an inflammation of the mastoid 
and tympanic cavity which extended less rapidly than usual to 
the periosteum and tissues lying upon it, and it was on this ac- 
count a concealed and dangerous foe. According to a theory of 
mine the second attack was essentially a new process attacking 
the former seat of disease, or locus minoris resistentice — "the 
weak spot," as patients say, induced by some exciting cause 
that is unknown. The integrity of the nerve, up to a late period, 
is shown by the amount of hearing power exhibited on the even- 
ing that the perforation of the bone was made. 



TREPHINING THE MASTOID — CASES. 517 

In the light of my present experience I would have advised 
Wilde's incision on first seeing the patient. For, although 
marked by absence of symptoms of suppuration in the tym- 
panum, it now appears plainly like the so-called primary in- 
flammations of the mastoid generally recognized. 

Agnew reports a case which has been alluded to in the ac- 
count of caries of the mastoid, an outline of which, made up 
from Dr. Agnew's report, is herewith presented. It is the case 
in which Dr. Crosby perforated the mastoid with a gimlet years 
before. 

Case III. — Acute Otitis Media — Mastoid Periostitis — Opening of Mastoid by a 
Gimlet — Subsequent Trephining — Hyperostosis of Mastoid Cells — Recovery. — Miss 

X , in middle life, caught cold and a sore throat, after exposure in the 

country on August 26, 1864. Immediately after she was seized with violent 
pain in the right side of the head and corresponding ear. On September 5th, a 
swelling began in the mastoid region, the severe pain from the ear having con- 
tinued until that time. On September 30th, the pain extended rather suddenly 
down behind the course of the sterno-cleido-mastoid muscle. On October 2d, 
an incision was made over the mastoid, and it was perforated by means of a 
gimlet by Dr. A. B. Crosby. Pus followed the incision through the periosteum, 
and also on the withdrawal of the gimlet. Dr. Agnew first saw the case a year 
after this, when there was considerable swelling of the auditory canal. The 
concha and mastoid region was tender to the touch, and over the centre of the 
mastoid was a small fistulous opening which passed into a narrow sinus, running 
through the bone toward the tympanic cavity. This sinus was with difficulty 
entered by a No. 4 Bowman's probe. The principal subjective symptoms were 
pain in the temporal bone, apprehension of brain disease, slight loss of memory, 
nervousness, and wakefulness. The face was anxious ; the operation was advised, 
but it was declined. 

In February, 1870, the x^atient had an alarming attack. The principal symp- 
toms were a feeling of " general agony," and paralysis of the right seventh nerve, 
with obstinate vomiting. This was on Friday, and on the Wednesday following, 
the paresis had disappeared, but there was some loss of memory and a slight 
degree of aphasia. 

On February 21, 1870, Dr. Agnew "proceeded to trephine the mastoid 
through a sweeping cut, using for the purpose a half-inch instrument (trephine) 
with the pin in the mouth of the sinus,'' a dense button of bone nearly three- 
eighths of an inch thick. Dr. Agnew believes that the cells were filled by a 
dense bony growth. Drs. Van Buren, Loring, Keyes, and myself were present 
at the operation. The sinus was enlarged by using a triangular steel bit. so that 
the entire depth of the track opened was about five-eighths of an inch. No pus 
was found ; no caries. of the bone. The patient experienced a marked ameliora- 
tion of her symptoms after the operation, and, as Dr. Agnew informs me, con- 
tinues well at this time, now three years since the operation. 

Dr. D. E. Ambrose, Assistant Surgeon to the Manhattan Eye 
and Ear Hospital, trephined the mastoid process, in a case of 



518 TEEPHIXIXG THE MASTOID — CASES. 

peculiar interest, the notes of which the doctor has given me, 
besides allowing me to see the patient. 

Case TV. — Mastoid Periostitis — Abscess — Incision — Polypoid Growths from 
Wound — Trephining — Bone found very dense — Removal of Plug one inch long — 
Recovery. — Miss S. C — — , aged nineteen, came under observation February 15, 
1872, complaining of deafness in right ear, and stated that about four years ago 
she had an attack of severe pain in that ear, accompanied with slight hemorrhage, 
and followed by discharge of pus. H. D. R. E., watch pressed upon auricle. 
Voice in very loud tone about six inches from the ear. There was a small quan- 
tity of cerumen adhering to the wall of canal. The membrana tympani was 
clearly visible, but showed evidences of previous trouble. Right Eustachian 
tube closed, and impervious to Politzer's method or the catheter, after frequent 
local applications of nitrate of silver. 

Left ear normal. 

The small quantity of wax having been removed, treatment by electricity 
was commenced and continued three times a week for about six weeks, at the 
expiration of which time H. D. R. E.; voice, in tone of ordinary conversation, 
distinctly heard at fifteen feet. This gave great satisfaction, as she had been 
much disheartened by prospect of complete and r>ermanent deafness of that ear. 
Patient was now discharged. 

On April 20, 1872, she had an acute attack of periostitis in external auditory 
canal, which involved the mastoid cells, and in spite of leeches, warm-water 
douches, and incision down to the bone of the canal, resulted in abscess of mas- 
toid cells. 

The abscess protruded through the posterior wall of canal, and, on being 
opened with a bistoury, discharged a considerable quantity of pus. 

The ear was now frequently cleansed with lukewarm water; but, notwith- 
standing this, there soon sprang from the mouth of the abscess polypoid growths, 
which astringents, including the solid stick of nitrate of silver, and several ex- 
cisions, failed to subdue. There still remained a constant aching, with, occa- 
sionally, sharp darting pains in mastoid process, which radiated to different 
quarters of temporal region. On two occasions patient found small, thin scales 
of bone in the purulent discharge. I then passed a silver probe, bent, through 
the opening of the abscess, and could distinctly detect dead bone, both in pos- 
terior and superior portions of mastoid cells. Meanwhile the mastoid process, 
at its lower portion, became red, slightly swollen, and very tender to the touch. 

On June 1, 1872, after making an incision two inches and a half long, down 
to the bone, parallel with the auricle, and half an inch from its attachment, 
I separated the periosteum from the bone to an extent sufficient to admit a 
quarter-inch trephine, and inserted that instrument on a line with sujjerior 
border of external meatus, and about half an inch from the attachment of the 
auricle, directing the instrument slightly forward in a horizontal position. 
After the trephine had penetrated to the depth of half an inch, and finding my- 
self on just as firm bone as at the commencement, I heartily wished the affair 
was over with ; but remembering that Troltsch says that "the depth to which we 
must go is sometimes very considerable," I regained my courage and persevered 
with the operation until I felt a slight yielding beneath the instrument. I im- 
mediately withdrew it and tried, with moderate force, to extract the plug of 
bone with bone forceps, to which, however, it did not yield in the slightest 



TREPHINING THE MASTOID — CASES. 519 

degree. Again the trephine was replaced, and, after a few more gentle turns, 
there was a very perceptible sensation of further yielding beneath the instru- 
ment ; and a second time the trephine was withdrawn and a second ineffectual 
effort made to extract the plug, though it yielded slightly to lateral pressure. 
The trephining was again renewed, and, after a few gentle turns, withdrawn ; and 
now the plug was easily extracted. The instrument was repeatedly withdrawn 
and very lightly worked after the first yielding was detected, lest by a sudden 
giving way of parts beneath, it should be suddenly plunged into the mastoid 
cells, and, in a moment, defeat all my hopes from the operation. The plug hav- 
ing been withdrawn, I was surprised at the small amount of pus that escaped, 
for this, together with the bone dust, certainly did not exceed one drachm. 
This led me to suspect that I had not entered the mastoid cavity at all ; and to 
remove all doubts upon this point, I passed a bent probe through the opening 
of the abscess, and another through the wound just made, and could distinctly 
touch and move the one with the other. 

The wound was then syringed with warm water, to which was added a few 
drops of carbolic acid, and then plugged with lint, which treatment was con- 
tinued daily, and sometimes twice a day, for six weeks, when the wound com- 
pletely healed, without any discharge from the ear, and without a single uncom- 
fortable sensation remaining. The constant aching and frequent darting pains 
with which the patient had been so long harassed were almost instantly relieved ; 
for the next day, after all effects of anaesthetic had passed off, she complained of 
nothing but the soreness of the wound, nor did she complain of anything more 
from that day throughout the entire healing process. The polypoid growths 
also, which had resisted all other measures that I had used, ceased, in a few 
days, to grow, and soon entirely disappeared, without any additional treatment 
than simply cleansing the ear. This was apparently a perfect cure until four 
weeks after the wound had healed — ten weeks from the date of the operation — 
when, after exposure to a draught of damp air, she was suddenly seized with 
sharp pain in the same ear, which was soon followed by a throbbing sensation. 

Examination revealed inflammatory action only on anterior and inferior walls 
of canal. The application of mild current of electricity would relieve ^11 pain 
within ten minutes, while a strong current aggravated it. But the pain would 
return again during the night, and sometimes within an hour after the appli- 
cation. Injections of warm water were then substituted with similar results, 
and patient was put on quinine and iron, and five grains of iod. potass, three 
times per day. These attacks of aching and darting pains became of very 
frequent occurrence — every two or three days, and sometimes as often during 
twenty-four hours — with an occasional discharge of a few drops of blood from 
the ear. Upon the superior wall of external canal there is a hard bony sub- 
stance, almost invariably covered with a purulo-gelatinous material, a little of 
which, on the end of the probe, emits a very offensive cadaverous odor. This 
part is very tender when pressed upon by the probe. 

H. D. E. E. Voice slightly raised above ordinary conversation heard dis- 
tinctly at fifteen feet. 

March 17, 1873. — I induced the patient to go to the Manhattan Eye and Ear 
Hospital, to get the advice of Dr. Roosa. 

I found the patient in a comparatively comfortable condition, 

able to pursue her ordinary avocation, and it seemed to me that 



o20 TKEPHINING- THE MASTOID— CASES. 

there was an exostosis of the osseous canal, and perhaps of the 
tympanic cavity, and that the pain was due to periostitis. I ad- 
vised the use of iodide of potassium and the continuation of the 
warm douche. The process of sclerosis of the osseous structure 
is probably going on. The change in the bone is similar to that 
which occurred in the preceding case. 

Case V. — Acute Suppuration of the Middle Ear — Vertigo — Mastoid Canes — Tre- 
phining — Fistula Closed in Fifty-six Days. — May 2, 1879. Mr. S , aged forty- 
seven. Boiler-maker. Has been hard of hearing and has had tinnitus "always." 
Seven weeks ago he was attacked by inflammation in the ear, caused by exposure 
to cold and dampness. He now has suppuration in the left tympanum, the 
drum-head being perforate. He also complains of vertigo and shooting pains 
running up over the forehead, down toward the occiput. H. D., E. 4 %. The 
warm douche and poultices behind the ear were advised. In a day or two 
leeches were applied on the tragus and upon the mastoid, and the patient was 
kept veiy quiet. The purulent discharge from the tympanum is free. He has 
slight pain in the tympanum and mastoid at night. Quinine was used, but 
without benefit. On May 28th he was having rather more pain and vertigo, the 
latter only when moving about. Slight tenderness over one or two points of 
the mastoid by very firm pressure. No thickening of the integument. Copious 
discharge from the ear. The canal is narrowed, and firni granular swelling at 
the bottom. No marks of drum-head or tympanum visible. Patient can at- 
tend to business, that of a superintendent. The pain is intermittent. An inci- 
sion, the patient not being under ansesthesia, about one inch long was made 
down to the bone. The bone felt softened and rough, but was not carious except 
at one spot. A probe was worked through this spot until it penetrated into the 
auditory canal. The opening was enlarged with the drill. No pus was found. 
The opening was plugged with lint and a poultice applied around the ear. The 
external excision was made T-shaped before the drilling was undertaken. The 
patient had some pain and dizziness until midnight. Absolute rest was advised. 
There is no fever. The patient did well until July 7th, with only gradual decrease 
of vertigo and pain. Last night he had an increase of dizziness and a feeling of 
numbness in the lips on the left side. The fistula in the bone has been closed 
for a week. The fistula in the soft tissues is still kept open. The canal looks 
well and there is only a moderate discharge from the tympanum. The air is felt 
in the ear on inflation, but there has been no perforative whistle for the last few 
weeks. 

July 21st. — The mastoid fistula has closed. Patient feels very well. H. 
D., tV; ™ce, 50'. 

August 5th. — The patient has been in the countiy since last date. Has had 
dizziness for about ten minutes after tipping back in a barber's chair, and he 
also suffers from it if he tips his head to the left, or lies on the left side. No 
vertigo in walking. 

August 11th. — Frontal headache for the past two days. More dizziness. 
Numbness of the left side of the nose and lip. Nothing wrong seen about the 
ear. Ordered bromid. potash, ten grains every two hours, and five grains of 
blue pill to-night. The patient recovered from this attack, took a voyage to 
England and back, and on November 29th he was seen and a final note made. 



TREPHINING THE MASTOID — CASES. 521 

There is now a slight purulent discharge from the tympanum. He had a slight 
bloody discharge from it, after climbing to the ball of St. Paul's Cathedral. The 
upper and posterior segments of the membrana tympani are now cicatrized. 
An opening exists below. The surface scar is granular. He complains of sore- 
ness of the left nostril and numbness of left side of upper lip (see August 11th). 
Face seems a little drawn, and uvula seems to tip a little to the right side. The 
patient has no vertigo or pain. 

This patient was hard of hearing- from the usual cause in a 
boiler-maker, but upon this supervened the inflammation of the 
tympanum and mastoid. The inflammation of the latter was 
only suppurative in a very narrow track, whatever it may have 
been in other parts. The tympanum, as shown by the facial 
paresis, was markedly affected. The first positive relief to his 
pain and vertigo came from the enlargement of the mastoid fis- 
tula by the drill. 

Case VI. — Caries of the Mastoid from Chronic Suppuration — Exacerbation of 
Otitis Media — Mastoid opened Three Times — Recovery. — Miss X , aged twen- 
ty-six. January 11, 1877. Six years ago, patient states that she had a discharge 
from the left ear without apparent cause. It has continued more or less ever 
since. Last September she took cold, and had severe pain with delirium. 
Swelling of the mastoid occurred, and in the last week of September it was 
cut. A free discharge of pus occurred and relief of the pain. The incision 
healed in a few days and the pain returned. The mastoid cells "were pierced" 
in October. The patient comes to me on account of continued pain and occa- 
sional dizziness. The left auditory canal is red, sensitive, and full of pus. 
There is a large cicatrix on the mastoid and a sinus running downward and for- 
ward toward the auditory canal. The physician who opened the bone afterward, 
wrote me as follows : "I found a fistulous opening where the mastoid had pre- 
viously been lanced. I at once made a free opening through the soft tissues 
into the cells. No pus was found. A fistulous opening existed between the 
osseous and cartilaginous meatus down quite into the middle ear. The opera- 
tion afforded very great relief from the urgent symptoms. But as the wound 
contracted pain recurred." 

About a month after, the Doctor again opened the wound, cut away as much 
of the diseased tissue as possible with a chisel, following the fistulous track. 
The probe detected diseased bone at the depth of one and one-quarter inches. 
Belief again occurred. Some time after a small piece of bone came away. The 
wound closed, but on January 6th swelling and pain in the mastoid again be- 
gan. The next day the wound again opened, and at this point she came under 
my care. After vainly attempting to get permanent relief from the pain, by 
keeping the fistula open with a tent, and treating the tympanum through the 
auditory canal, I determined to open the wound freely and enlarge the bone 
fistula. Accordingly, on April 7th, the patient was etherized. The external 
opening was enlarged, and the surface of the bone carefully examined. It was 
found to be smooth. The fistulous opening into the tympanum through the 
osseous canal was then enlarged with a drill, and the outer opening was made 
funnel-shaped. This fistula was treated by being dressed to the bottom with a 



522 CARIES OF MASTOID. 

tent, and healed June 23d, a little more than two months after the opening had 
been enlarged. The patient has been free from pain since a few days after the 
operation. The tympanum was treated through the auditory canal, by thorough 
cleansing with a syringe and curette, there being a great disposition to the in- 
spissation of pus and the formation of granulations, but she finally entered upon 
her duties as a teacher, which she continues (June, 1884) to perform. When 
last seen, in 1882, a part of a cicatricial membrana tympani existed, there was a 
free discharge from the tympanum, and a granulation in the upper part. Under 
the use of iodoform this became better. 

The final success in this obstinate case was due, I think, to a 
persistent care of the tympanic cavity, which was left free from 
pus and granulations, while the osseous fistula was being healed 
from the bottom. In opening the mastoid, the surgeon should 
remember, that the operation has become necessary because the 
pus is not thoroughly evacuated from the tympanum through 
the canal. There will, therefore, often be found much to be 
done in treatment of the canal and tympanum. 

Case VII. — Mastoid Caries in course of Chronic Suppuration — Opening of Bone 

— Relief — Death in about Three Months after from Cerebral Disease. — G. T , 

aged twenty. May 31, 1882. The patient has had a discharge from his right 
ear since infancy. He has had pain and swelling over the mastoid for two 
weeks. On the same day, I etherized the patient, I found that the right mem- 
brana tympani was gone, and that there was moderate suppuration in the tym- 
panum. I made a free incision one-quarter of an inch from the line of the 
auricle and found sound bone and no pus. I then made an incision parallel to 
this one-quarter of an inch further back. A fistula leading into the tympanum 
was discovered and about four drachms of pus evacuated. The fistula was en- 
larged with a drill, and a tent and poultice applied. The patient went to his 
home to be under the charge of another surgeon. He was free from pain. The 
opening into the bone was free, and a copious discharge existed from it and 
from the tympanum. I never saw this patient again, but I am informed by his 
family, that he died in August of the same year, rather suddenly from disease of 
the brain. 

The following case occurred in my own clinic, and although 
treated mainly by Dr. Ely and Dr. Brown, I saw the patient 
frequently, and advised in the later stages of treatment. It was 
reported by Dr. F. Tilden Brown in a special journal, 1 but it is 
of sufficient importance to be inserted here, since it illustrates 
what has been said of the occasional difficulty in diagnosis as to 
the presence of pus in the mastoid cells. 

Case Vm. — A Case of Abscess of the Mastoid, with entire absence of Tender- 
ness, Heat, or Swelling over the Suppurating Part, with a constant Distant Pain near 
the Occipital Protuberance — Trephining — Recovery — Occurrence of Erysipelas dur- 

1 Archives of Otology, vol. xii., 1883. 



CARIES OF MASTOID. 523 

ing Convalescence. — John McO , aged forty-eight, came to Dr. Eoosa's clinic 

at the Manhattan Eye and Ear Hospital on September 14, 1882. Examination 
by Drs. Edward T. Ely and F. T. Brown showed a muco-purulent discharge 
from the right ear, partial loss of the membrana tympani, diminished calibre of 
the auditory canal, no swelling or redness behind the auricle, no tenderness on 
pressure or percussion over the mastoid, inability to hear a watch on contact, tun- 
ing-fork heard but by aerial conduction. The sole cause of his coming to the 
hospital, was great pain at a point along the right superior curved line, two 
centimetres from the occipital protuberance ; occasionally radiating along the 
right border of the parietal suture over the frontal bone to its interior angular 
process ; thence above and below the orbit. 

Previous history. — No direct injury, but had a fall on back of head one month 
before. Had never had syphilis ; was perfectly temperate, and had always been 
well until the fourth of last June, when he experienced gradually increasing 
pain in the right ear. Morphine gave temporary relief. Five days after, a dis- 
charge appeared. The pain continuing, a blister was applied behind the ear, 
and on June 16th, he was able to go to work, but returned in a few hours with 
still greater pain. For the three weeks following, morphine (hypodermically) 
was given twice daily ; this failing, chloroform inhalation was resorted to. Late 
in July, Wilde's incision was made at the New York Eye and Ear Infirmary, but 
the pain became, almost at once, more intense. A few days later a bone-opera- 
tion was proposed, but the patient's family objecting, he came with a letter from 
his physician to the Manhattan Eye and Ear Hospital. Here careful watching 
for two days and nights verified his story of pain, sleeplessness, and loss of 
appetite, but no abnormal temperature was detected. 

The result of a consultation was to defer operation until thorough anti-neu- 
ralgic treatment had been tried. Quinine, alcohol, and galvanism were ordered. 
Five days later the patient was no better, and perforation of the mastoid was 
determined upon despite the absence of satisfactory local symptoms. It was 
performed by myself under the advice of Dr. Ely. The periosteum was healthy, 
and on its section the bone presented a similar appearance. Brainerd's drill 
sunk one and a half centimetre, entered a cavity, when about four grammes of 
pus came away. A warm solution of boracic acid, thrown into the meatus audi- 
iorius, found exit through the wound, bringing pus. The dressing was antiseptic 
and directed to favor free drainage and prevent occlusion. Pain was at once 
and permanently removed. Two w T eeks later the patient went home, but returned 
daily for dressing. The discharge now amounted to three grammes in twenty- 
four hours, and a watch could be heard on contact. On the evening of Novem- 
ber 4th, pain was felt about the auricle, followed by a chill with subsequent 
fever; the pain prompted a vigorous application of camphorated oil. Toward 
morning the patient vomited. I was sent for the following night when I found 
him with a pulse of 90 ; temperature, 103° ; tongue coated ; bowels constipated : 
pupils normal in response to light. Probe passed readily, but the discharge 
was slight. The tissues about the wound and over the parotid region were 
eedematous and but slightly sensitive ; this pallor suggested serous rather the 
haemostatic injection, and might have been either the erysipelatous cause, or 
the blistering effect, of camphorated oil applied to relieve deeper pain. The 
diagnosis of erysipelas was made on the fourth day ; this disease, still indiffer- 
ently marked, had extended to the left malar bone : pulse was 98 : temperature, 
103|°; delirious through the night; sight was indistinct; had convergent squint; 



524 CARIES OF MASTOID. 

pupils responded feebly to light; had moderately rhythmic vibrations of the right 
forearm. I was again led to doubt the absence of meningitis, and called Dr. 
Eoosa in consultation, who, on examination, found slight cerebral impairment 
and homonymous double vision existing ; the ocular media were clear. Optic 
disks not seen on account of want of illumination. The mastoid perforation was 
free, and afforded no evidence of retained pus, although the discharge was 
greatly diminished. For this reason Dr. Roosa and myself concluded that 
meningitis due to adjacent suppurative mastoid disease did not exist, and that 
the diplopia, with other nervous symptoms, was due to a peripheral hypersemia 
of the pia mater, by continuity of tissue with the facial erysipelas, resulting in 
irritation of the sixth nerve at its point of exit. 

This belief proved to be correct, for the intensity of the symptoms subsided, 
and in eight days convalescence began. The discharges from both channels had 
ceased, and one week later the wound completely closed. This was an agree- 
able surprise, for in its relationship to disease of the mastoid, I viewed the 
erysipelas as analogous to epididymitis succeeding a gonorrhoea, and I expected 
a return of the discharge as the erysipelas subsided. 

Dr. Brown gave the following points as being of special 
interest in this case : 

1. The entire absence of tenderness, heat, or swelling over 
the suppurating mastoid, while there was a constant pain re- 
ferred to a point near the occipital protuberance. 

2. The difficulty in differentiating the symptoms of facial 
erysipelas from those of meningitis. 

3. The direct suggestion made by the case, of the value of 
active counter-irritation in the treatment of sub-acute or chronic 
suppuration of the middle ear. 

I have now under treatment at the Hospital, a man of forty- 
five years, upon whom I performed the operation of trephin- 
ing the mastoid process for caries and abscess, in whom facial 
erysipelas developed in three days after the operation. Al- 
though he became very ill, having for some time a temperature 
of 105°, he recovered, and is now going about with a tent in the 
mastoid fistula, and with every promise of complete cure. The 
mastoid caries occurred during the course of acute suppuration 
of the middle ear, which he very much neglected. Although 
the patient was three weeks in bed from the facial erysipelas, 
the occurrence of this disease hardly seemed to retard the re- 
covery of the abscess of the mastoid. 

Besides the dangers of erysipelas and pyaemia from suppura- 
tive inflammation of the mastoid, it is not uncommon to meet 
with inflammation of the connective tissue of the neck, with 
the formation of abscesses. In the following case the life of the 
patient, was at one time threatened by the numerous abscesses, 
and his swallowing was for some days extremely difficult on 
account of the pressure upon the pharynx. 



ABSCESSES OF NECK EEOM MASTOID DISEASE. ?)2?y 

Case IX. — Acute Inflammation of the Middle Ear — Mastoid Periostitis vrifh 

Suppuration — Wilde's Incision — Abscesses in the Neck — Recovery. — Peter N , 

aged twenty-four. Admitted to the Manhattan Hospital, March 11, 1881. The 
following history was furnished by the House Surgeon : He is a fireman on a 
steamer, and is just convalescing from acute rheumatism. His right ear has 
been very painful and has discharged for some time until yesterday, when it 
stopped, and swelling and tenderness over the mastoid process occurred. 

The swelling extends below lobe of ear, on a line with anterior border of 
auricle, two inches, involving parotid gland ; backward, on straight line, two 
and a half inches ; upward, four inches ; forward, to a point on a line with the 
middle of auricle, two and a quarter inches ; then passing down and around 
auricle, along its posterior border, beneath the lobe, this line being about one 
and a half inches in length. The auricle itself is not swollen, the swelling 
shading off gently as it approaches it. There is considerable bulging over tip 
of mastoid and immediately below. An incision was made over mastoid and 
one an inch below. No pus found. Poultices were applied over region of 
swelling, a tent being introduced into the mastoid incision. Fifteen droj)s of 
tine, fern chloridi three times a day. Milk punch every four hours. 

Dr. Eoosa saw him on the 13th. He made a diagnosis of suppurative peri- 
ostitis. He thinks that the tympanic cavity is little involved. He made an in- 
cision down upon the periosteum in lower and back part of auditory canal. He 
advised delay until to-morrow, and then, if no discharge take place through the 
incision made, it will be best to put him under ether and find where the pus is 
and evacuate it. It will be imperative, should he have a chill. 

After the second incision the patient began to do well. The temperature 
gradually went down from 104° the day after he was admitted to 99|° six days 
after, but it rose again, but never higher than 101°. On the 15th, four days 
after admission, the swelling of the mastoid has extended an inch lower ante- 
riorly. The glands of the neck are enlarged. There is some pressure, so that 
swallowing is difficult. On the 17th fluctuation was distinct over the mastoid, 
and while patient was under ether, Dr. Ely enlarged the first opening over the 
mastoid, and about eight ounces of pus were discharged, a large portion being- 
pressed from the neck below. The probe was passed in all directions, to dis- 
cover if a counter-opening were practicable, but it passed so deeply into tissues 
of the neck, that it was considered unsafe. Tent twice a day. Poultices con- 
tinued. Discharge from middle ear excessive. Same general treatment has 
been kept up and to be continued. The ear is kept thoroughly clean with 
warm water. 

March 22d. — Ear discharging slightly. Swelling has receded from back of 
neck, but is prominent about parotid gland. The discharge from wound is free, 
and gentle pressure is used twice a day to evacuate pus lying below wound. A 
counter-opening was made 1 over greatest swelling below and a little to the 
front. The patient began immediately to improve rapidly, the swelling dimin- 
ishing. Has had much difficulty in swallowing for three or four days. 

March 23d and 24th.— Swallows better. Took oysters. Has been fed on 
beef -tea and milk almost entirely. 

March 25th. — Takes solid food for first time. Ate some beefsteak without 
trouble. Patient did uniformly w r ell until April 6th, when considerable swell- 
ing developed in lower and posterior part of neck, extending directly across 
from shoulder to spinal column. Tenderness over this region. Poultices were 



526 DISEASES OF THE MASTOID. 

discontinued on 5th, but were resumed to-day. Lower wound ceased to dis- 
charge. After thorough probing it recommenced. 

April 7th and 8th. — Patient doing better. 

April 9th. — Lower opening enlarged, to improve drainage. About 12th, a 
small abscess began to form about two inches below the mastoid wound. It 
was emptied from day to day, by gentle pressure through the mastoid opening, 
of a watery discharge. 

The rjatient now sits up, sleeps well, and has good appetite. The abscess 
is cleansed with solution of carbolic acid twice a day by means of a lachrymal 
syringe. The same general treatment kept up. 

The swelling anteriorly and below is increasing and interferes slightly with 
deglutition. This was opened and the patient was comfortable again for several 
days, when another abscess formed just above. It was small and emptied itself 
through one of the lower wounds. 

June 6th. — Patient looks fat and well. All wounds healed nicely. EL D., f&. 



CHAPTER XIX. 

THE CONSEQUENCES OF CHRONIC SUPPURATION OF THE MIDDLE 
EAR— (Concluded).— NEURALGIA OF THE MIDDLE EAR. 

Caries and Necrosis of the Temporal Bone. — Cases. — Treatment by Operation and In- 
ternal Medication. — Fatal Hemorrhage. — Cerebral Abscess. — Pyaemia. — Paralysis. 
— The Ophthalmoscope in detecting Cerebral Disease of Aural Origin. — Neuralgia 
of the Middle Ear. 



CARIES AND NECROSIS OF THE TEMPORAL BONE. 

The surgeon is often baffled in his efforts to check a discharge of 
pus from the ear, because it comes from a part of the bone — the 
walls of the tympanum — that has been softened by a carious pro- 
cess. It is not always possible to positively decide that the bone 
is in this condition, for the part thus affected may be sufficient 
to maintain a suppurative process, and yet be very small and 
hidden from view. Even the proper use of a probe in a diseased 
cavity of the tympanum, in order to enable us to decide as to the 
existence of caries, is a delicate matter, and should be under- 
taken with care, lest important parts be penetrated. The care- 
ful surgeon is, therefore, often in doubt as to how much of the 
bone may be invaded, even when he finds a superficial point 
that gives evidence of disease. The probe cannot be used in the 
ear as a diagnostic means, with that freedom that it is employed 
in solid parts that have no such important and delicate sur- 
roundings. 

All parts of the temporal bone may become carious as the 
result of a chronic suppurative process. The osseous portion of 
the auditory canal is one of the favorite positions for such a 
morbid change. The upper wall of this canal is but a short dis- 
tance from the dura mater and the cerebrum, and we have 
already discussed the relations of the mastoid cells to the lateral 
sinus. Thus we may have inflammation of the brain and affec- 
tions of the venous circulation, even when the caries is confined 
to the external ear. It is probable, however, that caries of the 
auditory canal is usually the result of a chronic suppuration of 



I 

528 CARIES OF TEMPORAL BOTTE. 

the middle ear, and not of a primary and independent affection 
of the peripheral portion. An exception to this has already been 
noticed in one of the chapters upon disease of the auditory canal. 
The anatomical relations of the cavity of the tympanum, than 
which there are none more important in the whole body, neces- 
sarily involve serious consequences from caries of any part of 
its walls. These consequences also necessarily include great 
impairment of the hearing, while we may have meningitis, cere- 
bral abscess, pyaemia, paralysis, or fatal hemorrhage. Indeed, 
in the treatment of any of these consequences of a chronic sup- 
puration, we are always treading upon dangerous ground, which 
may break under our feet at any moment. In some fortunate 
cases, however, none of these unpleasant results, except the loss 
of hearing, occur ; the diseased bone is thrown off, and the parts 
heal. Nearly the whole of the temporal bone may be cast off in 
this manner without involving the life of the patient. 

It has already been seen that the ossicula auditus may be- 
come carious and lost in the course of an acute suppuration. 
The same thing may occur in the course of a very chronic pro- 
cess, and small points of dead bone are frequently found when 
the cavity of the tympanum has been for a long time exposed 
from a loss of the membrana tympani. It is shown, however, 
from reports of cases by myself and others, that caries may 
occur with an intact drum-head. Dr. Orne Green 1 also pub- 
lished a report of a post-mortem examination, that illustrates 
the same fact. Dr. Geo. E. Francis, of Worcester, made the 
autopsy. 

A man twenty-five years of age, who was subject to catarrh, 
had had a discharge from his ear for two years ; at times acute 
symptoms occurred. Two months before death he could not 
hear conversation. He also had cerebral symptoms, dizziness, 
headache, double vision, and partial paralysis, but of what 
regions is unknown. He died comatose, and at the autopsy a 
collection of pus was found in the brain, just over a carious spot 
communicating with the tympanic cavity. The pus lay directly 
upon the bone. 

Dr. Green examined the bone, and found a sinus through the 
upper osseous wall of the auditory canal, just above and external 
to the small process of the malleus. The point of an ordinary 
probe could be inserted in this opening, and it communicated 
with the auditory canal and the small cavity in front of the 
handle of the malleus. From this cavity it passed backward 
and inward into a circular cavity about one-quarter of an inch 

1 Transactions of the American Otological Society, 1871. 



NECROSIS OF TEMPORAL BONE. 529 

in diameter in the cancellated structure of the bone. The roof 
of bone over this cavity had entirely disappeared, so that there 
was a direct communication with the brain. All the walls of 
this space were irregular and carious. " The membrana tympani 
was entire and apparently healthy, arid of normal transparency 
and thickness in every part beloiv the small process of the mal- 
leus bone.''' 

The head of. the malleus and the whole of the incus were 
wanting, but it could not be positively stated, that they were 
not removed during the dissection. They must certainly have 
been in a softened, diseased condition, or they would not have 
escaped so readily. Von Troltsch reported a similar case to 
this, and called attention to the little cavity, which is a part of 
the tympanic cavity, and is situated just above and external to 
the head of the malleus. In a normal condition, it is separated 
from the auditory canal by an extremely thin layer of bone. 
Von Troltsch dissected a specimen in which he found a polypoid 
growth springing from this point and projecting into the canal. 

Dr. O. D. Pomeroy * reported a case of exfoliation of the whole 
of the temporal bone, except the lower part of the external audi- 
tory canal and the inner part of the petrous portion. The patient 
recovered, of course with loss of hearing and facial paralysis. 
The patient was a boy aged twenty months, and had a dis- 
charge from the ear, accompanied, by severe pain for three 
months before Dr. Pomeroy saw him. There was mastoid peri- 
ostitis, and an incision was made. Two days after another was 
made, and the bone was found uneven and rough, and there was 
a fistula leading into the mastoid cells. For three months after. 
the child did moderately well, although there remained consider- 
able swelling in front of the auricle. At the end of this period. 
a small piece of dead bone was observed behind and a little above 
the external auditory canal, and in about a month afterward it 
became movable, and was grasped by forceps and some traction 
was made upon it, but so much hemorrhage was caused that the 
attempt to remove it was given up. 

Six months after the child was doing well. The aperture 
through which the sequestrum passed had closed. The dis- 
charge of pus was, moderate and the general health of the child 
was good. 

Wilde, 2 Agnew, 3 Gruber, 4 and Voltolini 6 have reported cases 
of the extraction through the external meatus of the whole of 



1 Transactions of the American Otologioal Society, 1872. * Text-book. p. 87. 

3 Von Troltsch on the Ear, American edition. 4 Lohrbueh, p 5& 

5 Monatsschrift fur Ohrenheilkunde, Jahrgan- IV., p. 84. 
34 



530 NECROSIS OF LABYRINTH. 

the internal ear, during the life of the patient. Wilde's case 
occurred in the practice of Sir Philip Crampton. The patient 
was a young lady, who, after the most urgent symptoms of in- 
flammation of the brain, with paralysis of the face, arm, and 
leg, and total loss of hearing of one side, recovered from the 
head symptoms and paralysis of the extremities after a copious 
discharge of pus from the ear. " One day Sir Philip, perceiving 
a portion of loose bone lying deep in the cavity of the meatus, 
drew out the whole of the cochlea and semi-circular canals." 

Dr. Agnew's case occurred in a patient who suffered from 
exostosis consequent upon chronic suppuration of the opposite 
ear, and who afterward died of brain disease dependent upon 
retention of pus by the exostosis. The case as regards the ex- 
ostosis will be found on page 486 of this work. 

The patient was a gentleman of thirty-eight years of age, 1 
who had suffered from chronic suppurative inflammation of 
the middle ear for the greater part of thirty-two years. Three 
years before the patient came under Dr. Agnew's observation, 
after a severe exacerbation of the aural inflammation, complete 
loss of hearing occurred in the ear, and paralysis of the facial 
nerve of that side. Granulations continued to recur constantly. 
On April 16, 1862, the patient was in a deplorable condition ; he 
had suffered for months from pain in the ear, loss of sleep, loss 
of appetite, and dizziness. The concha was swelled and ex- 
tremely tender ; a pear-shaped polypus, of fibrous character, 
which was kept bathed in very fetid pus, projected from the 
meatus. Dr. Agnew placed the patient under the influence of 
chloroform, and removed the polypoid mass by means of Wilde's 
snare. In attempting to get the snare about the base of the 
polypus, he encountered a solid body in the middle ear, which 
proved to be the necrosed internal ear. An incision was then 
made into the auditory canal, in order to enable the forceps to 
grasp the sequestrum. Dr. Agnew's report says : "Having got 
the body in the grasp of the forceps, a slight rocking motion, 
with traction, enabled me to extract it." The whole of the in- 
ternal ear — vestibule, semi-circular canal, and cochlea — were 
found to be removed. This patient lived four years after this, 
and never had any painful symptoms from that side of the head 
afterward. 

Gruber's case occurred in a child, thirteen years of age. 
Both cochleae were exfoliated, and yet the patient recovered, 
with no facial paralysis — an evidence that the cavity of the 
tympanum was left in a comparatively sound condition. 



1 American Medical Times, vol. vi. , p. 183. 



NECROSIS OF TEMPORAL BONE. 



531 



Voltolini's case was one that occurred in the practice of Dr. 
A. Jacobi, of Berlin. The whole labyrinth was removed from 
the ear of a child that is still living. The substance of the 
cochlea was not fully united with the surrounding bony sub- 
stance of the petrous bone, which, as Voltolini remarks, is evi- 
dence that the disease dates back to an early period in the life 
of the child. 

Toynbee J reported four cases of necrosis of the cochlea and 
vestibule, in which the parts had been exfoliated during life. 
One of them is Wilde's case, already quoted. The patients were 
adults, with the exception of one, a child of seven years old. 





Fig. 108. — Left Temporal Bone, from 
Case I. Exterior view, showing the exter- 
nal meatus : a, From which the anterior wall 
has been removed, as has also the inner wall 
of the middle ear ; 6, the mastoid process. 



Fig. 1C9. — Inner Surface of the same 
Specimen, showing : c, The vestibule ; c/, d, 
the windings of the cochlea, which have been 
exposed by sawing away portion of the bone ; 
e, the tympanum, communicating with/, the 
mastoid cells, which have been exposed by 
chipping away a thin layer of bone. 



The above engravings illustrate the ravages which chronic 
suppuration makes upon the bony tissue of the ear. They were 
made from photographs of the bones, and are from the collection 
of Dr. C. E. Hackley, who kindly allowed this use of them. 

History. — Case I. (Figs. 108 and 109). — Left temporal bone from a man who 
had phthisis, and died suddenly of pneumo-thorax, August, 1866. His hearing 
distance was nothing for the watch, nor could he distinguish words, though lie 
seemed to hear the sound of the voice. He was very much debilitated when he 
entered the New York Hospital, consequently no thorough examination was made 
of his ears. He had profuse discharge from both ears, and polypi on both sides. 



1 Archiv fur Ohronhoilkuiido, Bd. I., p. 113. 



532 



NECROSIS OF TEMPORAL BOXE. 



On the left side, the post-mortem examination showed polypus attached in the 
middle ear and extending forward into the meatus, and backward into the mas- 
toid cells ; membrana tympani gone ; stapes only one of ossicles present ; mem- 
brane of fenestra rotunda gone. 

Case II. (Fig. 110). — Left temporal bone from , who entered the New 

York Hospital August, 1866, with great fever and pain in the left ear ; had 
been sick two days. His disease ran mnch the course of typhoid fever, without 
marked head symptoms other than the acute jDain in the ear (which only existed 
the first few days). When a child he had discharge from the ear and past -aural 
abscess and disease of mastoid process. 

On the autopsy, pus was found under the dura mater and in mastoid cells ; 
the whole temporal bone was gone from the infiltration of pus through it ; the 
membrana tympani was completely destroyed ; the base of the stapes was the 
only part of the ossicula remaining ; there was an opening from the outer part 
of the bony meatus upward into a cavity which also had an opening outwardly. 




Fig. 110. — Left Temporal Bone, sawed through External Meatus, Middle Ear, and Coch- 
lea. The pieces are turned to one side, showing : a. Mastoid process ; b, &, external meatus, 
ending in c, the middle ear ; at d there was an opening downward through the bonj- meatus, 
and at e an opening upward, by which there was a free communication with /, the mastoid 
cells, which were separated from the interior of the cranium by a very thin layer of bone at 
g ; h, h, show the cochlea sawed through. (From Dr. Hackley's collection.) 



Case V. (Fig. 111).— August 18, 1868.— H. O applied at Xew York Eye 

and Ear Infirmary, on account of pain in right ear, saying he had a ' ' kernel " 
(wax ?) removed from his ear two years previously, by one of the surgeons of that 
institution. The right membrana tympani was found injected, right Eustachian 
tube obstructed. H. D. — Eight ear pressed; Left, £f. Applications of warm 
water, with occasional leeching, were ordered. After some time the walls of 
the meatus swelled so that the membrana tympani could not be seen. Under 
varying treatment the state of the case was sometimes better, sometimes worse, 
till March, 1869. During his attendance the patient twice stopped coming, 
thinking he was well, when he complained of pain over the right side of the 
head, starting from the ear. Expecting meningitis, he was taken as an in-patient 
at the Infirmary, April 1, 1869, treated again with leeches, cold to head, bromide 
of potash, and tonics. About May 1, 1869, he showed occasional delirium, and 



NECROSIS OF TEMPORAL BONE. 533 

contraction of the muscles of the nape of the neck ; had retention of urine ; 
pulse 110-130 ; temperature 102°. Died May 10th. No discharge from ear for 
thirty-six hours preceding death. On autopsy, twelve hours after death, we 
found the brain slightly congested ; the right optic nerve (which went to an 
atrophied eye) was atrophied both before and behind commissure ; the menin- 
ges of the base of the cerebellum, and upper part of the spinal cord, were cov- 
ered with lymph and bathed in sero-pus (about two oz.) ; right auditory nerve 
very red ; periosteum over the posterior part of the right temporal bone was very 
easily detached ; the bone under it was greenish, infiltrated with pus ; the pas- 
sage from the middle ear to the mastoid cells was much enlarged, with only 
a thin wall of bone between it and the brain. On detaching the pericranium 
this wall was broken through. Membrana tympani entirely gone ; the promon- 
tory was roughened ; the stapes was the only one of the ossicles left in position. 




Fig. 111. — Right Temporal Bone, from Case V., showing the Cranial Surface of the Bone. 
At a the bone was very thin, and broke away when the dura mater was removed ; the bone 
was much hollowed out about b, the middle ear. (From Dr. Hackley's collection.) 

Fig. 112, from a photograph given me by Dr. Sexton, is a 
view of the extensive ravages of disease of the temporal bone, 
perhaps of a traumatic origin. I first saw the case upon Dr. 
Sexton's invitation, and some time afterward, I was present 
when Dr. George A. Peters, under whose care he then was, per- 
formed the operation which is described in the following notes, 
kindly furnished me by Dr. Peters. 

St Luke's Hospital — Aural Polypi — Mastoid Disease — Dr. Peters, attending 

surgeon. — George R , aged forty-four, car driver, native of the United States. 

Admitted April 13, 1876. He was a sailor for several years, and received a good 
many blows about the head at that time. He denies any venereal complaint. 
Up to a year ago he was perfectly healthy ; at that time he had frequent attacks 
of vertigo, losing consciousness for a brief period. 

In June, 1875, he had quite a large abscess opened behind the right oar; 
there was a free discharge of pus, and in due time it closed. Some lew months 
ago he noticed that the right side of his face was paralyzed. About this time 
his doctor told him, that his right ear contained polypi. 

On admission his condition is pretty fair. Has had no marked attacks of 
vertigo for past few months; but his dizziness has increased and has become 
almost constant, so that he has been unable to work. Often feels a desire to 



534 



CARIES OF MASTOID. 



wheel around and around. There is marked paralysis of face on right side, and 
the patient imagines there is loss of power on same side, but examination does 
not seem to confirm his idea. There is a fluctuating tumor behind light ear. 

April 25th. — Exploratory puncture made, and 3 ij. of dark brown-colored 
serum was withdrawn. Since then the tumor has again become quite tense, and 
careful examination reveals marked pulsation. This impulse is probably due to 
pulsations of some branches of posterior auricular artery. 

Drs. Loring and Roosa advise the removal of polypi and an incision into tumor. 




Fig. 112. 



-Caries of Squamous aud Mastoid Portion of Temporal Bone, 
collection.) 



(From Dr. Sexton's 



May 5th. — The patient was etherized, Dr. Peters operating. Polypi could not 
be snared, so they were evulsed. Incision, three inches long, was made into the 
tumor ; the incision was perpendicular, and just over squamous suture extend- 
ing down beyond the mastoid process. No pus was evacuated, only serum 
tinged with blood. No large vessels were severed, not even a small artery, to 
which a ligature could be applied, and yet there was such a general and profuse 
oozing, that the wound had to be plugged, and a tight compress applied. Many 
small flat pieces of bone were taken away, and on passing finger into wound the 
mastoid portion of temporal bone was found to be extensively diseased and 
broken down ; so that the impulse of the brain could be perceived at the bottom 
of the wound. The amount of blood lost was considerable. 

May 6th. — He rallied very well from operation, but complains of extreme 
weakness. Does not suffer much pain. 

May 7th. — Temperature and pulse not much above normal. Dressing re- 
moved, bleeding quite profuse. Compresses reapplied. 

May 9th. — Compress removed. On looking into wound, the entire bottom 
of it (about the size of an old-fashioned cent) is seen to pulsate. Finger easily 
detects the pulsation, and here and there can perceive pieces of dead bone. 
There is still considerable oozing. Compress reapplied. An occasional dose of 
opium given. 



CARIES OF PETEOUS BONE. 



535 



May 10th. — He is stronger and better. No bleeding on removing com- 
presses. Wound washed out with carbolic water and dressed with lint soaked 
in carbolic oil. 

May 15th. — He sat up to-day. Carbolic lint dressing continued. Pulsations 
still perceptible. Fragments of bone can be felt and any attempt to remove 
them causes bleeding. 

May 26th. — Wound granulating and filling up rapidly. Can still detect a 
slight pulsation at bottom of wound. The intense headaches, of which he com- 
plained constantly before the operation, have entirely 
disappeared. Discharged cured. 

The patient succumbed to the disease 
finally, from meningitis. 

The history of the following case was 
given me by Dr. Cooper, of New Jersey, 
together with the specimen : 

Male, aged sixty-five. Gradually increasing blad- 
der disease for five years. Enlarged prostate. Cys- 
titis. 

First part of December, earache. Severe dis- 
charge in twenty-four or forty-eight hours. Three 
years before, trouble in same ear. Discharge was less, 
but the ear continued to trouble him. Pain behind it. 

January 5th. — Sudden and severe pain in head, in 
front and back. Stupor in twelve hours, and died 
January 8th, in morning. 

Head opened. Dura mater congested, and lymph at base of brain, 
dant pus, extending to the medulla. 




Fig. 113.— Caries of Pet- 
rous Portion of Right Tem- 
poral Bone (two-thirds size). 



Abun- 



Fig. 114 is from a specimen furnished from a case reported 
by me in 1875. ' 

The patient was a man of twenty-five years of age, who suf- 
fered from suppuration of the right ear for four years or more 
before his death. 

In consultation with Dr. Cameron and Dr. McKay, I saw 
the patient once, when he was dying from purulent infection, 
pleuro- pneumonia. The drum -head was entirely gone, and 
there was considerable inspissated pus lying in the tympanum. 
He had been suffering for some weeks from pain in his head 
and ear, with profuse purulent discharge. There was never 
any tenderness over the mastoid. For several days his tem- 
perature ranged from 102° to 103.5°. On May 8th lie had a chill, 
and on the 9th Dr. Cameron found pleurisy of the left side. On 
the same day another chill occurred, and on the 11th pleurisy of 
the right lung was detected, and double pneumonia. 



Transactions of the American Otologic;*! Society, p 



92. 



536 



PUS IX LATERAL SINUS. 



The discharge from the ear became more abundant, there 
was copious expectoration, the head symptoms were greatly 
alleviated, the mind became clear. But fixe days after, chilly 
sensations were again experienced and they were followed by 
intense pain over the region of the lateral sinus. Five days 
after this I saw the patient when he was unconscious, and, as 
has been said, there was a free discharge from the ear. There 
was also exophthalmus. He died the next day. 

The post-mortem examination was made by Drs. Cameron, 
McKay, Ely. and myself. 

Brain. — General congestion of the substance of the brain 
and very marked fulness of the vessels on the surface. No soft- 
ening. ISTo purulent collection ; thrombosis of the right internal 
jugular ; pus in the right lateral sinus. 

Thorax. — Suppurative pleuritis of the right lung. The entire 





Fig. 114. — Caries of Lateral Sinus of Right 
Temporal Bone (two-thirds size). 



Fig. 115. — Caries of Squamous Portion of 
Temporal Bone (right side, actual size). 



surface of the lung was covered with pus. There was also pus 
in the right lateral sinus. There were pus and serum in the 
pleural sac. 

Temporal bone. — There was no trace of the membrana tym- 
pani nor of the ossicles. The bony wall of the right lateral 
sinus was carious. The upper surface of the petrous bone was 
of a bluish color. The cochlea and semi-circular canals were 
not examined. 

Of Fig. 115 I can furnish no history. 



Prognosis. — The prognosis of caries and necrosis of the tem- 
poral bone depends upon several factors. To a marked degree 
it is influenced by the age of the patient. Young children will 
throw off quite large portions of the bone, and yet escape with 



CAEIE8 AND NECROSIS — PROGNOSIS. 537 

their iives, while older persons will usually succumb to one of 
the many consequences, such as pyaemia, hemorrhage, abscess, 
which may result from death of bone in this part of the body. 
The situation also of the dead bone will influence the prognosis 
of caries to a marked degree. Caries of the mastoid, especially 
when occurring in young children, is very often recovered from. 
Caries and necrosis of the walls of the middle ear is of course 
the most dangerous of all that may occur, especially caries of 
the upper and lower wall. It has been seen that the whole inter- 
nal or labyrinth wall may be destroyed, and the contents of the 
external ear be exfoliated, and yet the patient recover. In 
these cases the necrosed internal ear seems to have passed 
through a sound tympanic cavity. 

The prognosis of caries and necrosis of the temporal bone is, 
however, always grave under any circumstances, and no life 
can be said to be what the life insurance companies call a good 
risk, if a chronic suppurative process has gone on to this extent. 
The ossicula auditus may be thrown off with comparative im- 
punity, as we see by cases all about us; yet even these cases, 
unless the suppuration has entirely ceased, belong to a class of 
whose results we must always stand in dread. Until the parts 
have healed, and some kind of a neoplastic membrana tympani 
has formed, we are not safe in giving a decidedly favorable 
prognosis. 

Although the hearing power is often much better when the 
drum-head is gone or perforated, than when it is present in a 
cicatricial and thickened condition, it is much better to make 
every attempt to restore or close it. The presence of this mem- 
brane is essential to the safety of the patient from consequences 
much more serious than impairment of hearing. 

Treatment. — It is impossible to give any specific rules for 
treating caries and necrosis of the temporal bone. Each case 
must be judged by itself, under the general rules of treatment 
that have been given as appropriate for chronic suppuration ; 
the chief of these rules, I may venture to repeat, are a thorough 
removal of the accumulating pus before it has time to produce 
its corroding and destructive effects, and careful attention to 
the general health and habits of the patient. 

It will often be necessary to open the mastoid, and to cut into 
the bony wall of the canal to remove dead bone that is obstruct- 
ing a free outlet of pus. Those who will study the abundant 
literature of operations upon the diseased temporal bone. will. 
I think, be convinced that there is a large held here for skilful 
surgical interference. Life has been saved in many eases, a 



538 



CONSTITUTIONAL TREATMENT. 



very long and tedious suppuration prevented in others, by the 
timely creation of a fistula in the bone, with the result of secur- 
ing that sine qua non in cases of the constant formation of pus, 
thorough drainage. 

Of late the attention of the profession has been called to the 
alleged value of the sulphide of calcium, which drug, according 
to Ringer, has '"the property of preventing and arresting sup- 
puration " in cases of suppurations of the middle ear. Dr. Sexton ? 
argues earnestly, for the value of this drug in cases of disease of 
the mastoid and temporal bone, as he does for its employment in 
furuncular and external applications. I am not at all convinced 
that this drug, or any other, has any such specific value as is 
claimed for it. 

Dr. Theobald, 2 in a paper before alluded to on the constitu- 




PiG. 116. — A diagram designed to show the relations of the Tympanic Cavity to the Mas- 
toid Cells, the Jugular Fossa, and the Cavity of the Cranium. The inner wall of the cavity 
is exposed to view, with the round and oval windows and the promontory. M, Mastoid cells ; 
J, jugular fossa ; E, Eustachian tube ; B, base of brain. (A. L. Ranney.) 

tional treatment of ear disease, thinks the profession has gone 
too far in exclusively local treatment, and quotes a case of Dr. 
Buck's, from his book (p. 307) to support his views. It was that 
of a little girl of six years of age, who had alarming cere- 
bral symptoms in connection with a severe attack of acute in- 
flammation of the drum of each ear. The membranes of the 
drum were red and bulging. A free incision was made. On the 
following day the child was in a state of partial coma ; pulse 
140. Upon the advice of consulting surgeons mercury was given 
internally and externally (calomel and inunctions of the oleate 
of mercury), as well as bromide of potassium. An active dis- 

1 The Treatment of Diseases of the Middle Ear and Contiguous Parts by Milder 
Measures than those Commonly in Vogue. Medical Record, vol. xxi., No. 3, p. 57. 
"-Chapter XIV., his book. 



CONSTITUTIONAL TREATMENT. 539 

charge established itself during the night, and the child made a 
rapid recovery. Dr. Theobald believes that the change in this 
case was due to the mercury, but I think we have all seen just 
such changes occur where no drug was used, but when the sup- 
puration was encouraged by poultices, and the warm douche, or 
even when nothing was done. Dr. Theobald is an earnest advo- 
cate for the use of mercury in aural disease, and quotes with ap- 
proval Sir William Wilde, who valued the bichloride of mercury 
so highly in acute and chronic aural disease. I have given mer- 
cury a fair trial in public and private practice, and as I have 
already said in this book, I shall probably never go back to its 
use except as a tonic, in persons who have no syphilitic taint, 
much as I value the experience of Dr. Theobald, who recom- 
mends it so highly in almost every form of inflammation of the 
ear. On the other hand, I am more and more in favor of the 
early search for retained pus, so that if found, it may be liberated 
in time. 

Gruber 1 mentions one means of treating caries of the tem- 
poral bone, in which I have no experience, but of which he gives 
a favorable report, in some cases where the severe pain was not 
relieved by local antiphlogistic and anodyne treatment. This is 
the actual cautery. The iron is applied at several points over 
the mastoid process. After the bony slough is removed, an 
irritating salve may be applied to continue the counter-irrita- 
tion. Dr. Post, of this city, also speaks well of the actual cautery 
as a less painful means of treating mastoid periostitis than the 
incision. I have no doubt, judging from my experience in a case 
of Dr. H. G. Newton's — which I saw in consultation— where 
Dr. Newton trephined the mastoid process for continuous and 
severe pain referred to the middle ear, but without finding dead 
bone, that such openings will do very much to relieve the deep- 
seated pain of caries that is referred to the ear and the brain. 

The facilities for treating chronic suppuration, since we have 
Politzer's method of inflating the tympanum, are much greater 
than those enjoyed by our predecessors. We may, by the em- 
ployment of this method, more thoroughly cleanse the tympanic 
cavity from pus than by the simple use of the syringe. 

A patient with extensive caries of the temporal bone should 
be made aware of the gravity of his condition, so that he and 
his friends may be on the lookout for serious symptoms, which 
maybe promptly treated, and that they may not fall into the 
error of supposing that no harm can possibly come from u a 
simple running from the ear." 

If polypi or granulations have occurred in connection with 

1 Lehrbm-li, p. 552. 



540 FATAL HEMORRHAGE FROM CARIES. 

caries of the canal or tympanic cavity, they should be removed 
with care, lest severe hemorrhage occur, or other harm to the 
parts. The galvano-cautery has proved an efficient and safe 
means of removing such granulations, 1 and of causing the bone 
to heal. 

Fatal hemorrhage has occurred from caries of the bony 
canal, in which the internal carotid passes through the apex 
of the petrous portion of the temporal bone, as well as from 
destruction of the bony wall that separates the mastoid process 
from the lateral sinus, and also from the breaking down of the 
thin plate of bone that forms the floor of the cavity and sepa- 
rates it from the jugular vein. Fortunately for the lives of 
many patients, there is a tendency to thickening, or hyperplasia 
of the bony walls of the tympanum, in some cases, and thus 
they are protected from the corroding effects of pus. 2 

Hessler 3 has recently collected nineteen cases of hemorrhage 
from the internal carotid, in consequence of caries of the tem- 
poral bone. One of these is Billroth's case, here quoted from 
Gruber. A case in Hessler's own practice led him to look up 
the literature of the subject, which he found uncollected. This 
was that of a woman, who died suddenly, while suffering from 
caries of each tympanum, from an enormous hemorrhage from 
the mouth, nose, and right ear. In thirteen of the cases col- 
lected by Hessler the diagnosis was rendered certain by a post- 
mortem examination. One of these was his own. In the six 
remaining cases, although a necroscopy was not had, it is prob- 
able that death resulted from hemorrhage of the carotid. 

He closes his valuable article with an account of three cases, 
in which the section after death revealed complete absence of 
the osseous canal of the carotid, and although this canal had 
been surrounded by pus, no hemorrhage had occurred. 

The first case quoted by Hessler is from Boinet (Archiv gen. 
cle Med., xiv., 1837). The patient had suffered for seven years 
from chronic suppuration. He had then severe hemorrhages in 
two days and died. The second is from Chassaio-nac's treatise 



1 Archiv fur Ohrenheilkunde, Bd. YT., p. 116. 

2 Gruber : Lehrbuch, p. 543. Gruber states that Billroth has tied the common 
carotid artery for a case of aural hemorrhage, which occurred not from caries, but 
from a congenital defect in the bony wall. The hemorrhage ceased for ten days after. 
After all attempts to restrain the hemorrhage were fruitless, Billroth ligated the left 
carotid, and two days after the patient died from severe hemorrhage from the right 
ear, the nose, and mouth. A child, for whom parents would not allow the operation, 
died from the same cause. Koeppe reports a case of hemorrhage from the lateral 
sinus, through the nose and ear. This was in consequence of destruction of the bone. 

3 Archiv fur Ohrenheilkunde, Bd. XYIIL, p. 1 et seq. 



FATAL HEMORRHAGE FROM CARIES. 541 

on "Suppuration," L, page 529. He had suffered from aural 
disease for six months, suppuration and facial paralysis for six 
weeks. He also had tuberculosis of the lungs. He had three 
hemorrhages in three days and died. Plugging the external 
auditory canal only caused the blood to run out through the 
Eustachian tube. Two cases are quoted from Toynbee. In one 
of his cases, the patient also had phthisis pulmonalis. The fifth 
case is from Baizeau (Gaz. d. Hop., page 88. 1861). Here also 
was phthisis. The patient was a soldier, twenty-three years of 
age. For ten months he had had chronic suppuration of the 
ear. The hemorrhage occurred after coughing. The common 
carotid was tied, but the bleeding recurred and the patient died. 
In the sixth case, from Choyan, there is no mention of disease 
of the lungs. There were three hemorrhages, in a patient who 
had suffered for several months from chronic suppuration (Ar- 
clfiiv gen. de Med., May, 1866). Broca, in 1866, reported a case 
of tuberculosis of the lungs, caries of the temporal bone, with 
several hemorrhages. The hemorrhage was stopped by ligation 
of the common carotid, but the patient died soon after from 
tuberculosis. 

The remainder of this series of cases also tend to show, that 
fatal hemorrhage, from caries of the bony surroundings of the 
carotid artery, is especially apt to occur in phthisical patients. 
In one case, that of Piltz, the patient was syphilitic. His lungs 
were sound. The carotid was tied in three of the nineteen cases. 
In none of the cases, however, was the hemorrhage permanently 
arrested, but in one case death did not occur for two months and 
a half. The time from the first hemorrhage until death varied 
from five minutes to thirteen days in those cases, in which the 
carotid was not tied. In two of the cases in which the carotid 
was tied, death occurred in twenty and twenty-four days respec- 
tively. Thus far, no essential results have been obtained from 
treatment, either by the tampon, digital compression, or ligation 
of the carotid. The nature of the disease, forbids any but a bad 
prognosis. When the bleeding is not from the carotid but from 
the tympanum, or a polypus springing from this part, the prog- 
nosis is generally good. Thorough plugging the bottom of the 
canal, with the use of persulphate of iron, will generally arrest 
the hemorrhage, but here we are not dealing with a large vessel. 

CEREBRAL ABSCESS. 

The proceedings of pathological societies and surgical rec- 
ords show, that abscess of the cerebrum more frequently results 
from disease of the middle ear than from any other single cause. 



542 CEREBRAL ABSCESS. 

Of seventy-six cases of cerebral abscess collected by Drs. Gull 
and Sutton/ twenty-five, or about one-third, were directly trace- 
able to chronic suppurative processes in the middle ear. Le- 
bert, 2 in his article upon this subject, considers that aural dis- 
ease is the cause of cerebral abscess in about one-fourth of the 
published cases. 

Toynbee's catalogue contains ten cases of cerebral abscess 
from aural disease. 

There is usually caries in connection with the cerebral ab- 
scess, but cases have occurred in which, although the disease 
of the ear extended to the brain, there was no death of bone. 
The anatomy of the cavity of the tympanum, especially of the 
roof, or tegmen tympani, where a process of dura mater actu- 
ally extends into the tympanic cavity, and where there may 
normally be a gap in the bone, has taught us how easily this 
may occur. The cause of the extension of a suppurative pro- 
cess to the brain is undoubtedly very often that which Mr. 
Toynbee so clearly sets forth in his chapter on this subject — 
that is, the non-escape of the pus externally through the mem- 
brana tympani. The perforation of the membrana tympani in 
acute inflammation usually prevents any such disaster as the 
passage of the pus to the brain or the circulation. 

Rupture of the membrana tympani is, therefore, a conserva- 
tive process, if suppuration has once been established ; for there 
is no other safe way of escape for the pus, except through the 
Eustachian tube — a means of exit which is one of the last that 
nature chooses. Abscess of the brain in acute disease was only 
once observed by Mr. Toynbee, but it has since been observed 
by myself. 

A direct communication usually takes place between the 
diseased mastoid or petrous portion of the temporal bone and 
the brain substance through the meninges, but the dura mater 
and other membranes may be healthy, and even a portion of 
healthy brain may lie between the diseased bone and the cere- 
bral abscess. The chronic disease of the ear may be going on 
very well, until some mechanical injury — exposure to cold, or 
the like — sets up an acute process, which extends to the brain 
through the delicate bony walls of the tympanic cavity, or the 
cancellous structure of the mastoid bone. 

Patients suffering from chronic suppuration of the middle 
ear cannot be too much guarded against blows or falls upon the 
ear, or against exposures to sudden changes of temperature, 

1 Reynolds' System of Medicine, vol. ii. , p. 544. 

2 Virchow's Archiv, Bd. X., p. 391. 



CEKEBRAL ABSCESS. 543 

draughts of air, or the like ; for the histories of many cases 
show that meningitis, cerebral abscess, and pyaemia may, from 
such exciting causes, be the determination of a purulent dis- 
charge from the ear. 

The symptoms of disease of the brain are sometimes very 
insidious. At times there is a chill or a convulsion, or nausea 
and vomiting ; at others, only increased pain in the ear, fol- 
lowed in rapid order by paralysis, coma, and death. In very 
rare cases there are absolutely no symptoms, except those of a 
chronic suppurative process in the ear, until death occurs. 

The table of fatal cases of aural disease resulting from 
chronic suppurative processes, added to this chapter, was com- 
piled from various sources, in order to show the variable char- 
acter of brain symptoms supervening an otitis media purulenta, 
and the anxiety with which such a case, especially if united 
with caries or necrosis of bone, should be regarded. 

It is interesting to note how slowly the profession came to 
recognize the fact that when pus was found in the brain com- 
municating with the ear, that it was on its way inward, and 
not making an external opening. It seems to have been hard 
for the medical men of a few generations back, to believe that 
aural disease could cause any serious affection, or that it was a 
matter of much account, although people were dying all about 
them from the results of aural disease alone. Lebert 1 says that 
Morgagni, "with his good tact and close observation of Nature," 
discovered that the ear was often the cause of purulent affec- 
tions of the circulation and brain substance ; but Itard took a 
step backward, and discovered a kind of cerebral abscess which 
broke out through the ear. Lallemand again placed the subject 
in its right light, and showed, what we now clearly see, in cases 
of cerebral abscesses occurring in connection with suppuration 
of the ear, that the organ of hearing was the part first affected. 

It is generally believed that a suppurative process in the ear 
is necessary for the production of an abscess of the brain, and 
this is probably the fact ; but one case that I observed, leads me 
to suspect that there may be such a thing as a chronic cerebral 
abscess leading to disturbing aural symptoms, such as tinnitus 
aurium and pain in One side of the head, without any primary 
aural affection. I treated a gentleman of about twenty-nine 
years of age, for some months, for such symptoms as have been 
indicated, and when he died a cerebral abscess was found. He 
could hear the watch only three inches from the left ear. which 
was the affected one, and the drum membrane was sunken. I 



1 Virchow's Arehiv, Bd. IX., p. 368, 



544 CEREBRAL ABSCESS. 

supposed the case to be one of chronic proliferous inflammation 
of the middle ear. The patient got no relief ; he became very 
despondent on account of his tinnitus aurium and pain, gave up 
his business, and died at Sag Harbor, L. L, of malignant pus- 
tule, about two years and a half after I first saw him, and three 
years and a half after his first aural symptoms. Dr. George A. 
Sterling, of that place, made a post-mortem examination. He 
found "great injection of the pia mater over petrous portion of 
temporal bone, and an abscess about the size of a ten-cent piece 
in the brain substance. It was bounded by inflammatory adhe- 
sions, and contained about ten drops of pus. The abscess was 
situated on the left side, in the superior lobe, one inch from the 
median line and two inches from the coronal suture.*' This pa- 
tient never had a suppurative inflammation in the ear, and it 
is possible that the cerebral abscess was the cause of his very 
distressing symptoms, although the data are not full enough to 
allow us to give a positive opinion. There is no account of an 
examination of the temporal bone. 



PYEMIA. 

I have already in this volume related two cases, one of which 
was fatal, which show that pyaemia, or metastatic abscesses, 
from the entrance of pus into the circulation through the mas- 
toid veins or the lateral sinus, may result from aural disease. 
I will here add another, which was under the care of Dr. Ely and 
myself, and which also resulted in recovery. It has already been 
published, 1 but chiefly with the view of pointing out the inter- 
esting fact, that the recovery occurred without the use of medi- 
cine. It is important enough to be inserted in this connection 
for it illustrates more than one point in aural practice. I quote 
from Dr. Ely's account of the case : 

Chronic Suppuration of both Middle Ears^ — Mastoid Periostitis — Wilde's Inci- 
sion — Opening of Cells by a Probe — Relief for Seven Days — Chill — Pyaemia — 

Recovery. — Louis S , aged fifteen, has had chronic suppuration of both 

middle ears for many years. During the past year he has been treated in the 
clinic of Dr. Eoosa and myself at the Manhattan Eye and Ear Hospital, and 
nothing unusual has been observed about his case until lately. On the after- 
noon of January 20th he was brought to me with well-marked mastoid periostitis 
on the right side. The cause of this inflammation was not evident. The red- 
ness, tenderness, and swelling were confined chiefly to the anterior two -thirds of 
the mastoid process, and the swelling was not very great. There was severe 
pain in that side of the head, and marked constitutional disturbance. An im- 



Archives of Otology, vol. x. , p. 41. 



PY/EMIA. 545 

mediate operation was advised, but was declined by the family. The boy was 
taken into the hospital, however, and four leeches were applied. When seen by 
me at half-past eight the next morning, he was decidedly worse. There was 
high fever — a temperature of 104£° — and great jjain in the right side of the head. 
With the assistance of the house-surgeon, Dr. Cox, I made a Wilde's incision, but 
found no pus. The bone exposed by the incision seemed sound ; but after con- 
siderable burrowing under the anterior flap of the wound, I detected a softened 
spot in the bone through which a stiff probe was gradually worked into the 
mastoid cells, and a small quantity of thick pus then escajjed. After the fistula 
had been enlarged, a tent was inserted, a poultice applied, and the hot douche 
ordered to be used every two hours. The operation was performed under ether. 
The bad symptoms were immediately relieved. At 1 p.m. the temperature was 
101^°, and it fell rapidly to the normal. The mastoid tenderness and swelling 
subsided. The patient seemed to be making a speedy recovery, and I considered 
him out of danger. The wound was syringed with carbolized water and the tent 
changed twice a day ; and the ear was douched frequently with hot water. Ex- 
cepting that some pain persisted in the frontal and right temporal regions, there 
ajDpeared to be a progressive improvement in all respects until January 27th. 
Early in the morning of that day he suddenly had a chill, and the temperature 
at 9 a.m. was 104^°. He complained of pains in various parts of the body, espe- 
cially in the left knee-joint, the throat, and along the right external jugular vein. 
All these points were very tender, particularly the track of the vein, but there 
was no external redness or swelling. The discharge from the wound became 
less. Between this date and February 8th he presented well-marked symptoms 
of pyaemia* He had irregular chills and sweats, and a temperature varying 
irregularly between 99J° and 105°. His tongue at first was brown and dry, and 
then became very red, dry, and glazed. There was great prostration, a rapid 
pulse, and a dusky pallor of the skin. There was marked increase of the previ- 
ous deafness on both sides. He was restless at night, and may have had slight 
delirium, judging from the account of his friends who sat with him; but no 
delirium was observed by any of his medical attendants. His pupils always 
appeared normal. He had some cough and complained of pains in his chest but 
I could find nothing abnormal by physical examination. Several copious clay- 
colored stools occurred. His general condition was so alarming that I thought 
he would surely die ; and this was the opinion also of Dr. Boosa, who saw him 
frequently in consultation with me. An unfavorable prognosis was given to the 
family. 

Additional features of his sickness may be gathered from the following some- 
what incomplete notes, which I made from time to time : 

January 28th. — Pains the same as yesterday. Pains also in right axilla, along 
the inner edge of the right biceps muscle and in the right knee. All these 
points very tender. 

January 29th. — Discharge from the wound more abundant, of dark brown 
color, and fetid. [This continued for five days.] Pains the same. 

January 31st. — Pains and tenderness along each clavicle. A rod and tender 
swelling about the size of a walnut has appeared over fehe left sternoclavicular 
articulation ; distinct sense of fluctuation. 

February 2d. — Pains and tenderness along clavicles, shoulders, and arms. 
Less tenderness along jugular vein. 

February 5th. — Bed and painful swellings, apparently glandular, in the neck. 
35 



546 pyemia. 

below mastoid, right side. [Deep suppuration occurred in the tissues of the 
neck subsequently, and the pus was evacuated through the mastoid opening.] 

February 12th. — Swelling over clavicle gone. [All who examined this swell- 
ing had diagnosticated fluid contents, but no incision was made into it.] Opened 
an abscess in the gum over the second molar tooth, right upper jaw, and evac- 
uated considerable pus. The whole right side of the face was flushed, swollen, 
and tender. A probe in the incision passed about li inches upward over the 
exterior of the bone. Patient sits up for the first time. 

There were no unfavorable symptoms after this date. The convalescence 
was slow, and the patient was not strong enough to leave his room until Febru- 
ary 20th. He went out February 26th. At that time there was a free discharge 
from the mastoid fistula and from the ear, and the hearing was ^ c ff . 
Below is a partial record of the temperature : 
January 21st,— 9 a.m., 104*° ; 1 p.m., 101$° ; 7 p.m., 101*°. 

22d.— 9 a.m., 101° ; 7 p.m., 101°. 

23d.— 9 a.m., 100° ; 7 p.m., 99^°. 

24th.— 9 a.m., 99° ; 7 p.m., 99° 

25th.— 9 a.m., 98i° ; 7 p.m., 98£°. 

26th.— 9 a.m., 99° ; 7 p.m., 98|°. 

27th.— 9 a.m., 104i°; 7 p.m., 101£°. 

28th.— 9 a.m., 104 c ; 12 noon, 104|° ; 7 p.m., 103|°. 

29th.— 9 a.m., 104|° ; 12 noon, 105° ; 10 p.m., 103f°. 

30th.— 9 a.m., 100^° ; 2 p.m., 103°. 

31st.— 9 a.m., 100° ; 10 p.m., 99i°. 
From February 1st to February 8th. — The temperature varied between 99° 
and 101°. 

This case is interesting not only on account of its fortunate 
termination, but because it serves to illustrate the natural course 
of the disease in question ; for, throughout his illness, the patient 
took no drugs whatever. This plan of treatment was adopted at 
the outset from my conviction that no drug would arrest the 
septic poisoning, and that the large doses of quinine often used 
were capable of doing harm. This view was shared by Dr. Roosa 
in all my interviews with him : but it evidently excited wonder 
in the minds of some of the medical visitors who happened to be 
attending the clinics at the time. This very common feeling of 
surprise at seeing any alarming sickness treated without the use 
of what is by so many considered essential, shows that many 
minds can profit by the study of just such a narrative as has 
been given above. 

Aside from the matter of drugs, this boy, of course, had a 
great deal of medical treatment, in the best sense of the words. 
He had a quiet room to himself with an open fire : some member 
of his family sat with him each night, and he had the efficient 
nursing made possible through the kind supervision of Dr. Cox. 
as well as the latter's constant medical observation. I visited 
him often myself, and every small detail regarding food, stimu- 



PYAEMIA. 547 

lants, dressings, etc., received thoughtful consideration. For- 
tunately, food was well borne during the entire period. The 
diet consisted of milk, to which was added a little sherry wine 
at first, and afterward a little whiskey. Poultices were kept 
applied over the jugular vein and upon the painful swelling over 
the left sterno-clavicular joint. The free action of the bowels 
was doubtless useful in eliminating the poison, as has been re- 
marked of other similar cases. Might not large doses of quinine 
(through their astringent action) have tended to check these 
desirable movements of the bowels, in addition to the depressing 
effect they might have had upon the nervous system ? 

As soon as the crisis of this boy's illness had passed, the im- 
provement in the expression of his face and in his whole aspect 
was so striking, that it would naturally have been attributed to 
any medicine that he might have been taking at the time. Still 
more natural would such an inference have been regarding the 
rapid disappearance of the abscess — for such I believe it w r as — 
over the clavicle. 

Another interesting point is that the sanitary condition of our 
hospital is considered unusually bad just at present. 

I examined this patient a few days ago (May, 1884). There is 
a very slight purulent discharge from each tympanum, which is 
carefully removed by the patient and occasionally by one of the 
surgeons of our hospital. He is in excellent health, hears con- 
versation addressed particularly to him, about two feet away. 

Mr. Prescott Hewitt, 1 in 1861, related a case of pyaemia, and 
with the like happy result of recovery. Mr. Hewitt's case was in 
substance as follows : A young lady, eighteen years of age, had 
a discharge from the ear, as a consequence of measles. About 
four weeks after the occurrence of the discharge, she was seized 
with severe chills, which were followed by much fever, a furred 
tongue, and typhoid symptoms, with suppression of the dis- 
charge. When Mr. Hewitt saw the patient the chills continued, 
the skin had assumed an earthen hue, and the fever was; intense. 
The intellect was clear, but there was pain extending down the 
side of the neck, along the course of the jugular vein, and the 
head was inclined to that side. There was swelling at the base 
of the neck. In eight days pus appeared in one of the sterno- 
clavicular articulations. In a few days one knee became in- 
volved, and symptoms of pneumonia appeared, which s<>on sub- 
sided. In about seventeen days from the beginning of the 
phlebitis, swelling and pain occurred over one of the hip- joints, 

1 London Lancet, February '-2, 1861. 



54S PYEMIA. 

a deep abscess formed, but it was opened early, and the joint did 
not become involved. The patient ultimately recovered under 
treatment by wine and morphia. 

This case and the one already referred to. give the clinical 
features of purulent infection from suppuration in the ear. The 
pathological characteristics of the disease are seen in the table 
of fatal cases appended to this chapter. Professor Lebert : has 
given us the fullest account of the inflammations of the sinuses 
that may lead to purulent infection ; but the proper limits of 
this volume do not allow of a fuller discussion of this dangerous, 
but by no means hopeless disease. 

Dr. Hessler.' of Halle, has recently collected the published 
cases of pyaemia in acute suppuration of the middle ear. He 
includes but one of mine, and that he doubts somewhat. There 
are eight cases in his table. The case of mine which Hessler 
reports, is that on page 383 of this volume. He is inclined to 
consider it a case in which two diseases happened to occur at 
the same time — an acute innammation of the middle ear and a 
septic phlegTiion of the left foot. I am tolerably familiar with 
the symptoms of pyaemia, and although the case was originally 
reported to show the harmful results from the use of the nasal 
douche, and not the symptoms of pyaemia. I well remember 
the discoloration of the veins of the neck, the chills, the ab- 
- esses, and the pyaeinic odor, which plainly marked this case 
as one of pyaemia, not only to me, but to Dr. Swift and Dr. 
Peters, who attended the case with me. The history shows 
that pus found its way into the circulation from the tympanum 
through the jugular vein. If Dr. Hessler had carefully exam- 
ined the Transactions of the American Otological Society and 
the Archives of Otology, he could have added two cases to 
his table from my practice, which, whatever my first case was. 
were typical cases of pyaemia. To return to my first case, how- 
ever, coincidental phlegmonous inflammation of the foot, seems 
to me out of the question as a diagnosis, just as much as is 
endocarditis, which another German authority made for me. in 
reviewing the ca-^. ; 

Because it was not stated in the history that the chest was 
examined. Dr. Weber-Lael assumed that an endocarditis might 
have been overlooked, as does Dr. Hessler. It is hardly neces- 
sary to say that the patient had no endocarditis, and that the 
patient's chest as well as other parts of the body that are not 

" Vir --how's Arehiv. Bd. IX.. p. 3S1. 

- Arehiv. f&i Ohrenheilkimde, Bd. XX.. p. 333. 

1 Mc -: fur Ohrenheilkunde, 1869, p. ISO. 



PARALYSIS. 549 

mentioned in the case, were carefully examined. Hessler ad- 
mits, however, that, not having himself seen my case, he may 
be mistaken in his opinion of it. 



PARALYSIS. 

Paralysis of the seventh nerve, as it passes through the tym- 
panic cavity, in the Fallopian canal, must of necessity be a 
consequence of many suppurative and carious affections of this 
part, and yet it cannot be said to be a frequent affection in the 
course of chronic suppuration of the middle ear. In the greater 
number of the cases in which it occurs, it is permanent, from 
the fact that the nerve-tissue is destroyed by the ulcerative pro- 
cess ; but I have seen several cases of temporary paralysis of 
the seventh, which were probably due to pressure upon the 
nerve-trunk ; for, the functions of the nerve were finally re- 
stored, and the face resumed its normal appearance. 

Paralysis of other parts of the body, and complete hemi- 
plegia, may occur in the course of meningitis and cerebral ab- 
scess ; but these necessary consequences of the destruction of 
brain substance hardly require a separate notice. 

It is possible that a blood-clot might form between the dura 
mater and the bone, from rupture of a branch of the middle 
meningeal, from caries of the temporal bone, and hemiplegia be 
induced by pressure communicated to the motor tract, or as 
Mr. Hutchinson says, as quoted by Dr. Hughlings Jackson, 1 by 
squeezing the blood from the corpus striatum, or thalamus op- 
ticus. The author has published two cases of hemiplegia, oc- 
curring in coincidence with chronic suppuration of the middle 
ear, 2 which are here reproduced as good illustrations of the sub- 
ject, although it is not claimed that they should be regarded as 
positively consequences of chronic suppuration. A boy ten 
years of age was brought to me for advice on May 10, 1869. He 
had had a discharge from the left ear since he was an infant, 
and about four weeks ago he was affected with a number of 
paralytic symptoms that came on gradually. He became un- 
able to speak distinctly, or to swallow his food properly, and 
finally he could not walk steadily. There was paralysis of the 
seventh pair on the left side, and of the left arm and leg, so that 
he could not grasp well, and he dragged his foot in walking. 
These symptoms came on gradually, in the course of some 
hours, a fact which indicated hemorrhage between the dura 

1 Reynolds' System of Medicine, vol. ii., p. 505. 

£ Transactions of the American Otologic*] Society, 1870. 



PARALYSIS. 

mater and the bone. The right membrana tympani was in:: 
but thickened, and it had no light spot. The left was ulcerated 
and perforated. Its remains were very vascular. Kis hearing 
distance was rr from the right ear. and ^\ from the left. 
Under the usual treatment the membrana tympani healed, and 
the hearing power became normal. The paralysis was nearly 
gone when he disappeared from observation. 

June 8 3 1870. — Tne patient was again brought to me. and 
his mother stated that he was seized with dizziness and loss of 
sight while at school. He became so affected that he was fif- 
teen minutes going two or three blocks, and he was stupid when 
he reached home, although he had complete control of all his 
limbs. He had sight enough to go about, but not to read. T 
months after this attack, his vision was | with the right eye. and 
J with the left The field of vision was greatly limited on the 
periphery. The ophthalmoscope did not detect any lesion in 
the fundus oculi. Under expectant treatment the boy slo~ 
recovered his vision. 

The second case was that of a farmer, aged six:y-:w.;>. whom 
I saw in October. 1869, in consultation with Dr. Losee, of Red 
Hook, N. Y. The patient had suffer* I :: m jhronic suppura- 
ti d of the right ear. since he was a child. Occasionally acute 

ttacks would occur, culminating in abscesses of the mast 
Foi six years past, the ear had been very quiet. About six 
weeks before I saw the patient, he was seized with hemiplegia 
of the left half of the " : :Iy. coming on in the course it a fe w 
h v.: - When I saw him he was slowly recovering from the 
paralysis. The hearing power on the right side was completely 
lesti yed The cavity of the tympani was exposed and empty 
There was a cartilaginous band extending across the canal, 
which I divided, and found that it contained small bits of dtad 
bone, which seemed to come from the posterior wall of the canal. 
The patient fully recovered from the paralysis, and is still living. 

Dr. Hughlings Jackson. 1 in lecturing upon epileptic, or epi- 
leptiform convulsions occurring in connection with discharges 
from the ear. says, that arguing from the fact that cerebral or 
cerebellar abscess may follow disease of the ear. "it becomes 
legitimate to inquire if minute changes in tracts of the brain 
may not occasionally follow a disease of this apparatus, which 
changes may allow occasional discharge of nerve force."' H- is 
anxious to learn if epileptiform seizures occurring in case- : 
discharge of pus from the ear. may not result from minute 
changes in venous tracts. There are still great gaps in our 

: British Ke lieal Journal. June 86. 18GS 



OPHTHALMOSCOPE IN AURAL DISEASE. 551 

knowledge of epilepsy and paralysis dependent upon aural dis- 
ease. 1 L)r. Jackson urges that in all cases of hemiplegia in chil- 
dren the ear should be examined, and that in such autopsies the 
possibility of venous thrombosis from aural disease should be 
borne in mind. 



THE OPHTHALMOSCOPE AS AN AID TO DIAGNOSIS IN DISEASES OF THE 
BRAIN RESULTING FROM AURAL DISEASE. 

Dr. Kipp 2 called the attention of the profession to this sub- 
ject. Since then I am constantly availing myself of the assist- 
ance of the ophthalmoscope, in cases of chronic suppuration 
with serious symptoms. I cannot say that I have been able as 
yet to make a diagnosis by the examination of the entrance to 
the optic nerve, the retina, and its vessels, that I did not make 
from the study of the general symptoms and of the ear, yet I 
think that a more general use of this assistance in diagnosis 
may develop important results. Whenever we have a case of 
acute or chronic suppuration of the ear, with symptoms of cere- 
bral disease, such as severe pain in the head, vertigo, nausea, 
vomiting, or delirium, the ophthalmoscope may be of service in 
determining whether disease of the base of the brain exists or 
not. That there is effusion along the course or at the origin of 
the external muscles of the eyeball during the course of menin- 
gitis and meningeal hypersemia from aural disease is well estab- 
lished. One such case is recorded on page 522 of this book, where 
recovery ensued. Dr. Kipp found double optic neuritis in four 
cases of meningitis from aural disease. Two of them recovered. 
In the first case the optic disks swelled so much as to completely 
obliterate their margins. The arteries remained of normal size, 
but the veins became enlarged and tortuous. There was also 
paresis of the sixth nerve of the right eye. In five months there 
was no abnormal appearance in the optic papillae except that 
they were whiter than normal. In twenty-six months, the child 
was well as to her eyes, both optic disks and retinae were normal 
in appearance, and vision was normal. There was still some 
discharge at intervals from each ear, and the drum membranes 
were perforated. In the second case, which was a fatal one, 
optic neuritis appeared in ten days after Dr. Kipp saw the case. 
In this there was central caries of the mastoid cells, abscess of 
the right middle lobe of the brain, and thrombosis of the right 

1 The relations of epilepsy to aural disease, will be discussed somewhat in the chap- 
ter upon diseases of the internal ear. 

2 Archives of Otology, 1870, p. 147. 



552 OPHTHALMOSCOPE IX AURAL DISEASE. 

lateral sinus. In the third case reported by Dr. Kipp optic 
neuritis was found after the patient had been suffering from 
acute suppuration with mastoid abscess for a month. It may 
have existed long before this, but the patient did not come under 
Dr. Kipp's observation for some time after the serious symptoms 
appeared. The disks became very much swelled, so that a glass 
of nine inches focal distance measured the hypermetropia at the 
optic papillae, while at the maculae the retinae were of normal 
refractive power. In six months the patient was in excellent 
health, without discharge from the ears, and the optic disks 
were of normal color and flat. The vision was perfect. In the 
fourth case there was meningitis, thrombosis of the lateral sinus. 
The retinal vessels were found full and tortuous two days after 
the appearance of acute symptoms. The patient died on the 
eleventh day and before this had well-marked optic neuritis. 
Albutt * and Wreden 2 had previously noted optic neuritis in cere- 
bral disease from otitis. Both of Albutt's cases recovered. In 
Wreden's case, the intra-cranial disease was caused by a neo- 
plasm originating in the nasal cavity. 

It is an exceedingly interesting fact, that even the serious 
forms of optic neuritis seen in connection with acute suppura- 
tion may be entirely recovered from. No especial drugging was 
resorted to in these cases, but the treatment was pre-eminently 
local. Had even small doses of any drugs have been admin- 
istered, they might have been quoted in spite of the energetic use 
of the knife, poultice, and drainage as proofs of the specific 
power of drugs in arresting suppuration. 

Dr. J. A. Andrews 3 followed up this subject by reporting four 
cases, in which optic neuritis was observed in connection with 
aural suppuration. In one case recovery occurred. Andrews 
would accept oedema of the optic disk in chronic suppurations of 
the middle ear, that were not behaving well, as an indication for 
opening the mastoid, and if not with the expectation of liberat- 
ing pus, at least to establish free drainage from the middle ear. 
Andrews quotes a case from Zauf al (Inaug. Dissertation, Zurich), 
of a student, aged sixteen, who suffered from purulent otitis 
media and optic neuritis. After the mastoid was opened, the 
neuritis subsided and the patient made a good recovery. 

An interesting discussion followed the reading of Dr. Andrews' paper, to 
which those specially interested are referred. 



1 On the Use of the Ophthalmoscope, Appendix, 42 and 43. 

2 Archives of Ophthalmology and Otology, vol. v., Xo. 1, p. 75. 

3 Transactions of the American Otological Society, 1883, p. 138. 



CEREBRAL ABSCESS. 553 

In one case of death from meningitis following acute sup- 
puration of the ear, that came under my observation, the post- 
mortem examination showed, that the pus might perhaps have 
been reached by trephining the mastoid process, although this 
part of the temporal bone gave no signs of disease during the 
progress of the case, and an incision was made down to the bone 
for the purposes of examination. After much consideration of 
these cases, I am greatly inclined to advise that a thorough 
search should be made for pus, and by an opening through the 
bone, in all cases where death seems to be threatened from a 
cerebral abscess. I can see no reason why the surgeon should 
sit with folded arms, when there is a certainty on one side that 
death must ensue without interference, and a possibility on the 
other, that the use of the trephine might save life by the evacua- 
tion of an abscess. Surgery certainly has something to hope for 
in the more careful search for pus beneath the skull. Trephin- 
ing for abscess of the cerebrum cannot be a more dangerous pro- 
cedure than when undertaken for depressed bone, or for epilepsy. 
In saying this, I have no desire to retract anything of what was 
said in a preceding chapter upon the performance of unnecessary 
surgical operations. Most of the searches for the pus in abscess 
of the brain would probably result in failure. I have myself 
failed in the one case in which I attempted it, but one success 
would atone for many failures, for it would save a life. 

The table on the following pages, which I have compiled from 
various sources, illustrates in a striking manner the fatal con- 
sequences of some cases of aural disease. Taken in connection 
with the fact already stated, that suppuration of the ear is more 
frequently the cause of cerebral abscess than any other one dis- 
ease, these cases form a complete justification, if one were 
needed, for the giving up so much space to the consequences of 
chronic suppuration of the middle ear. If the table shall startle 
some mind hitherto inattentive to this subject, into a realization 
of its grave importance, and lead to a more careful consider- 
ation of an ulcerated middle ear, it will have accomplished its 
object. 



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NEURALGIA OF THE MIDDLE EAR. 561 



NEURALGIA OF THE MIDDLE EAR. 

Neuralgia is usually understood to be a disease of the sen- 
sory nerves, characterized by paroxysmal pain, without the 
objective appearances of inflammation, and which occurs in the 
course of nerves. In this sense neuralgia of the ear is an ex- 
tremely rare disease. Yet it does sometimes occur, and when 
it does, the pain is generally referred to the tympanic cavity 
and the osseous portion of the auditory canal. Its origin is 
sometimes to be found in carious teeth, and in the existence of 
malarial or syphilitic poisoning. 

Acute inflammation of the middle ear, of a catarrhal or even 
of a purulent form, was formerly often mistakenly supposed to 
be neuralgia. Better means of diagnosis, and a consequently 
better knowledge of morbid appearances, have greatly dimin- 
ished these errors, but even to this day the diagnosis of otalgia, 
figures more largely than it should. 

The supply of sensory nerves to the tympanum, Eustachian 
tube and auditory canal, is so large, that it would be strange if we 
did not occasionally meet with a case of pain referred to these 
parts, without any redness of the drum-head and canal, or swell- 
ing of the tube. Undoubtedly, if the seat of pain could be ex- 
amined in such cases, the nerve-tissue or its covering would 
show a pathological condition, either to the naked eye or the 
microscope, yet there are no inflammatory symptoms, in the 
ordinary sense of the term, in neuralgia of the ear, except pain, 
with perhaps sensitiveness of the canal and mastoid process. 
Neuralgia of the ear may occur in debilitated and overworked 
persons, and also in chronic catarrhal and chronic proliferous 
inflammation, as well as in chronic suppurations in anaemic 
subjects, and in the course of secondary syphilis. In neuralgia 
of the middle ear from diseased teeth, like that of the eyeball 
and eyelids, there are no inflammatory symptoms, but in the 
earache occurring from difficult dentition, either the reflex pro- 
cess leads very rapidly to trophic changes, or the pain in the 
ear, like that of the gums, is of inflammatory origin from the 
start. The continuity of the mucous membrane of the mouth 
with that of the bony Eustachian tube and tympanum, which is 
especially close in young children, is sufficient ground for sus- 
pecting that the pain in the ear in such subjects, is simply an 
inflammation that has extended from the gums to the middle 
ear. Be this true or not, and I believe it is, infantile earache. 
occurring in dentition, is practically an inflammation, as gener- 
ally understood, and not a neuralgia. 

30 



562 NEURALGIA OF THE MIDDLE EAE. 

Great importance is ascribed by certain writers to the condi- 
tion of the teeth in the causation of diseases of the ear. Sexton ' 
says that of fifteen hundred aural cases seen by him "perhaps 
one-third owe their origin or continuance, in a greater or less 
degree, to diseases of the teeth." This is a surprising statement 
to me, for on a careful consideration of my own cases of aural 
disease, now reaching in public and private practice more than 
ten thousand in number, I have notes of but very few, not more 
than one in a hundred, where it seemed to me that the condition 
of the teeth had any positive influence in causing or maintain- 
ing the aural disease. The cases that I have seen, were chiefly 
among infant children, who suffered from acute otitis media, at 
the same time with an inflammation of the gums. I have, how- 
ever, seen a few cases where ulcerating teeth produce what is 
apparently reflex neuralgia of the middle ear. I have also in 
my ophthalmic practice seen paresis of accommodation and 
keratitis instantly relieved, and ultimately cured, after the re- 
moval of carious teeth. I am very far then from denying that 
decaying teeth, or swelled gums, may produce reflex disturb- 
ances in the ear, but I think the number of cases of aural disease 
thus caused is small. Infantile earache during dentition is usu- 
ally an acute catarrh or acute suppuration of the middle ear; 
and not a neuralgia. This inflammation is, I think, even after a 
consideration of the theories of Woakes, 2 caused by an extension 
of the inflammation of the mucous membrane of the mouth and 
pharynx to that of the Eustachian tube. When a reflex aural 
disease is induced by the condition of the teeth, it is usually of a 
neuralgic and not inflammatory character, although of course, 
if the disease of the nerve or of its sheath, or whatever neural- 
gia may be, be continued long enough, changes in other tissues 
may occur. 

Dr. C. H. Burnett 3 reports the case of a physician, who con- 
sulted him on account of impairment of hearing, tinnitus, and a 
peculiar sense of discomfort in the left ear. The drum-head 
was "lustreless, opaque, and retracted." In a year neuralgia in 
the post-auricular region, with a constant and pounding tinnitus, 
synchronous with the pulse and a peculiar tapping noise not 
synchronous with the pulse. There was also ear-cough, but not 
excessive. All of these symptoms came on and kept up during 
excessive pain in the first molar tooth in the upper maxilla of 
the same side. This tooth was filled ten years before and the 



1 American Journal of the Medical Sciences, vol. lxxix. , p. 18. 

2 Deafness, Giddiness, and -Noises in the Head. Second edition, p. 16 et seq. 

3 The Specialist and Intelligencer, November 1, 1880. 



NEURALGIA OF THE MIDDLE EAR. 563 

aural symptoms had first shown themselves six months after 
the tooth was filled. An abscess finally formed, and the tooth 
was extracted, with instantaneous relief from all forms of tinni- 
tus, tapping sounds, and neuralgia in the ear, and the ear-cough 
and the hearing became much better. 

Bonnafont 1 devotes considerable space to neuralgia of the 
ear, and says that the disease rarely attacks both ears at once, 
but that it readily passes from one to the other, in consequence 
of the sympathy between the two sides of the fifth pair. There 
is apt, according to the same author, to be injection of the con- 
junctiva and lachrymation, in connection with otalgia. 

The seat of otalgia may be, according to Bonnafont, in the 
auditory nerve, the chorda tympani, or the nerve-supply of the 
tympanic cavity. Bonnafont advises instillation into the ear 
of a concentrated decoction of poppy-heads, and cataplasms or 
blisters on the auricle and mastoid process. 

Gruber 2 reports a case of typical otalgia cured by the use of 
iodide of potassium. Quinine was tried, but proved of no service. 

Gruber thinks it possible that there was an exudation press- 
ing upon the nerve in this case. The symptoms were spasmodic 
contraction of the left side of the head, with pain in the ear 
occurring at irregular intervals ; the longest intermissions were 
a few days. The hearing power was normal, and there were no 
pathological objective symptoms. 

I have seen and treated cases of neuralgia of the middle ear, 
which I thought to be of malarial origin. In one case, that of a 
physician of twenty-seven years of age, who had suffered for 
some months from acute pain referred to the tympanum and 
mastoid process, recovery promptly ensued on the use of quinine. 
I have seen a few others in hospital practice, but I have no notes 
of the progress of the cases. Each case of neuralgia of the ear 
should be studied by itself. The diagnosis is of great impor- 
tance, for one of the most valuable of remedies for neuralgia, 
quinine, is usually very harmful when administered in the course 
of catarrh or suppuration of the middle ear. Indeed in large 
doses, it is also harmful in all the inflammations of various 
parts of the ear. Its use should be avoided in all persons who 
have hyperemia of the auditory apparatus, or in those who 
readily suffer from inflammation of tlie middle ear. I have seen 
neuralgia in the ear in the course of syphilis, usually as one of 
the later manifestations. Here of course the usual anti-syphilitic 
treatment by means of mercury and potash will be of service. 



1 Traits the*oriqne et pratique des maladies de I'oreille. Paris, 1873, p. 531 

2 Monatssclirift I'm- Ohrenlieilkunde^ Jahrgang III., No. 9. 



564 NEUKALGIA OF THE MIDDLE EAR. 






If the cause of neuralgia be once found, whether it be a decayed 
tooth, the poison of syphilis or malaria, or general anaemia, the 
treatment will be simple enough. From all I have seen, I can- 
not believe that there is any considerable number of chronic 
aural diseases of the non-suppurative variety, that are in any 
way caused by the condition of the teeth. It is not very rare, 
however, to find a neuralgic disease added to a chronic suppura- 
tive process, when there is no active inflammation going on, and 
also in the course of the non-suppurative disease of the same 
part. Until it can be proven that people with sound teeth have 
a particular immunity from disease of the ear, it is hardly 
proper to assume that what may be a coincidental condition, 
decayed teeth — ill-fitting and improperly constructed plates for 
false teeth — are actually causes of any considerable proportion 
of the cases of chronic aural disease. 

I have carefully examined the teeth of my aural patients for 
some years, and I have failed to find that there was any strik- 
ing connection between chronic disease of the ear and bad teeth. 
Indeed, some of the most distressing cases I have known, were 
in people with particularly good teeth. 

CASES. 

The following case illustrates the subject of trophic changes 
in the middle ear, which were perhaps caused by a neurosis, in 
its turn produced by dental irritation. The patient lives in 
Italy, and I have never learned whether the diagnosis proved 
to be correct. 

Case I. — Deafness, Tinnitus, Itching, and Pain in the Left Ear for Two Years 
— Neuralgia of Jaw and Face on same Side, Disease about and in Last Molar Tooth. 

— September 15, 1882. Mrs. , aged forty. Has had deafness, tinnitus, pain, 

and itching in left ear for two years. Neuralgia of jaw, face, shoulder, and arm 
of left side for some time. Dizziness and nausea quite often for some time ; 
dizziness without nausea before. Has had a great deal of neuralgia before, and 
is subject to headaches. Hearing distance, right ear, ft ; left ear, iu- Tuning- 
fork heard on vertex, but in left ear (?). Bone conduction better than aerial on 
each side. The patient has a hard swelling high upon gum above last molar 
tooth of left side. She has had an ulcerated tooth there with similar swelling, 
requiring lancing, further forward. Present swelling increasing in size ; not 
tender. Eight membrana tympani opaque ; fair light spot ; fair position ; left 
membrana tympani opaque ; fair light spot ; fair position. 

Inflation only felt after two trials with chloroform. Hearing distance left 
ear, after inflation, ||. 

Diagnosis.— Neuralgia and trophic changes in tympanum from irritation of 
fifth nerve. 

Advice. — Inflation, and advised to have the gum and tooth treated. 



CASES OF NEURALGIA OF THE MIDDLE EAR. 565 

Case II. — Primary Syphilis — Miscarriage — Nocturnal Pains in the Shin Bones 
— Sore Throat — Neuralgia of Tonsil, Ear, and Eyeball — No Impairment of Hearing 
on the affected side — Sub-acute Catarrh of the Middle Ear on the other side. — Mrs. 

O , aged twenty-four, February 21, 1884. Patient was married three years 

since. Three months after marriage she miscarried, and soon after had severe 
nocturnal pains referred to the shins, and closely following severe pains in the 
head. Two years after marriage she had sore throat. Six weeks ago she had a 
very sore throat, and severe pain referred to the tonsil, Eustachian tube, middle 
ear of the right side. This pain continues, although not constantly, and is much 
worse at night. The patient has been under careful treatment by mercury, pot- 
ash, and great attention to the nutrition for the whole time since the mis- 
carriage. She is in fair condition, but suffers very much from the pain in the 
throat and ear. Her husband states that he contracted syphilis two years before 
marriage, but that he had no symptoms at the time of the marriage. He had a 
chancre, alopecia, papular eruption, and indurated cervical glands. None of 
these symptoms, except the latter, now exist. 

The hearing distance for the watch on the right side is about ££. Aerial con- 
duction better than that through bone. On the left side the hearing distance is 
reduced to -/ 8 -, and the aerial and bone conduction are about the same. There is 
no pain whatever on this side. The patient is not aware that she is at all hard of 
hearing. Does not know that she ever had any earache as a child. Both drum- 
heads are sunken and opaque, and the light spots are small. The pharynx is 
secreting an excessive amount of muco-purulent material. It is also swelled. 
There has never been any dizziness in the course of the disease. The upper 
teeth are false. One of the molars on each side is absent ; the other teeth are 
not sensitive. On inflation the hearing distance of the left ear became normal. 

Thanks to the frankness and intelligence of the husband of 
this patient, I was enabled to get a full history of the syphilitic 
origin of this case, the wife being ignorant of it. My diagnosis 
was neuralgia of the fifth nerve of the right side, of syphilitic 
origin, and sub-acute catarrh of the left tympanum. It was a 
striking instance of the different forms of disease in one and 
the same person. On one side was a syphilitic, well-marked 
neurosis, and on the other a syphilitic catarrh. 

While preparing these pages for the press, Dr. Ramsdell, one 
of the staff of the Manhattan Eye and Ear Hospital, called my 
attention to a case of severe neuralgia of the middle ear, which 
occurred in the course of a chronic suppuration of the tym- 
panum. The pain was decidedly different from that occurring 
from an increase in the inflammation, for example, in mastoid 
periostitis, being of an intermittent character. It was relieved 
by large doses of opium, and the inflammatory process made no 
advance while the neuralgia was under full headway. A true 
inflammation of the lining membrane would have only been re- 
lieved by antiphlogistic means. The patient was an anaemic 
woman of twenty-two years of age. 



TPIE INTERNAL EAR. 



CHAPTER XX. 

ANATOMY AND PHYSIOLOGY OF THE INTEKNAL EAR. 

The Vestibule, Semi-circular Canals, Cochlea, and Auditory Nerve. — Physiology of 

the Internal Ear. 

Galen named the internal ear the labyrinth, although he did 
not attempt to describe its various parts. This name it con- 
tinues to bear, although so much labor has been given to its 
exploration, that we now have the thread to guide us through 
its devious passages. Yet in our own time, a part of this in- 
ternal ear — the cochlea — is still the subject of vigorous research 
and heated discussion, and different views are yet entertained 
by competent authorities as to the true description of its com- 
ponent parts. I shall attempt to give the student such an ac- 
count of its anatomy as shall serve as a basis for the study of 
its physiology and diseases, without entering into the discus- 
sion of the points still unsettled. 1 

The internal ear may be conveniently studied by dividing it 
into the following parts : 

1. The vestibule. 

2. The semi-circular canals. 

3. The cochlea. 

4. The auditory nerve. 

We shall first study the osseous envelope of these parts, and 
then consider their contents ; the latter being, of course, far 
more important. 

THE VESTIBULE. 

The vestibule is considered by all authorities to be an essen- 
tial part of the internal ear. A part answering to the vestibule 
is to be found in all animals in whom an auditory apparatus 
can be detected. It is the seat of the principal expansion of the 
auditory nerve upon the saccule. This saccule floats in the peri- 



1 In compiling this anatomical sketch, the text-book of Henle has formed the basis 
of the description of the microscopic anatomy of the labyrinth. 



570 



THE VESTIBULE. 



lymph, and communicates through that fluid with the membrane 
of the fenestra ovalis, and consequently with the air in the tym- 
panic cavity. 

The vestibule is an irregularly shaped osseous cavity, the 
diameter of which from above downward, as also from behind 
forward, is about one-fifth of an inch. It is about one-tenth of 
an inch between its inner and outer wall. The semi-circular 
canals open into it by five orifices behind the cochlea, by a 
single one in front. The fenestra ovalis is on its outer wall ; 
above this is the anterior opening of the horizontal semi-circular 




Fig. 117.— The Left Vestibule, with the 
Semi-circular Canals, from an Adult, seen 
from within. (Riidinger). 1, The horizontal 
semi-eircular canal ; 2, the upper semi-cir- 
cular canal ; 3, the posterior semi-circular 
canal; 4, a bristle is passed through the 
aqueductus vestibuli, and passes into the 
opening of two canals, and appears on the 
upper wall of the vestibule ; 5, the mouths 
of the osseous ampullae of upper and hori- 
zontal semi-circular canals ; 6. the opening 
of the lower ampulla of the posterior semi- 
circular canal, below the numbers 6 and 7 ; 
7, the lower opening, in which the bristle is 
seen, represents the opening of the common 
passage for two semi-circular canals* 




Fig. 118.— The Vestibule (after Riidin- 
ger). 1. The osseous lamina spiralis of the 
cochlea, beginning below and posteriorly on 
the wall of the vestibule ; 2, the scala tym- 
pana and the fenestra rotunda ; 3, the scala 
vestibuli ; 4, fenestra ovalis ; 5, the posterior 
inferior wall of the lower ampulla, with the 
inferior macula cribrosa, which serves as a 
passage for the fibres of the vestibular nerve 
to the lower ampulla ; 6, fovea rotunda, or 
recessus hemisphaericus ; in its centre are a 
number of fine openings, the macula cribrosa 
media ; through these the fibres of the middle 
branches of the vestibular nerve pass to the 
round saccule, which is the blind vestibular 
end of the scala vestibuli ; 7. the upper por- 
tion of the recessus hemillipticus, in which is 
the upper macula cribrosa ; 8, the lower por- 
tion of the recessus hemillipticus, which 
passes without any distinct dividing line into 
the semi-circular canals. 



canal ; on its inner are several minute holes, making up the 
maculae cribrosse for the entrance of a portion of the auditory 
nerve from the internal auditory canal. At the posterior part 
of the inner wall is the orifice of the aqueductus vestibuli, a 
fine canal penetrating the vestibule from the posterior surface 
of the petrous bone, and contains a tubular prolongation of the 
lining membrane of the vestibule, ending in the cranial cavity, 
between the layers of the dura mater. 

The maculae cribrosae on the inner wall of the vestibule, are 



VESTIBULE AND SEMI-CIRCULAR CANALS. 571 

to be seen with the naked eye on the newly born, but in the 
adult they are only to be seen by means of the microscope. 
Henle describes four little groups, each having five openings, 
and each series of foramina make up what is known as a ma- 
cula cribrosa. Through the macula cribrosa superior, the nerves 
pass to the utricle and to the ampullae or flask-shaped openings 
of the anterior vertical and the horizontal semi-circular canals. 
The nerve -fibres to the posterior semi -circular canals pass 
through the inferior macula cribrosa, and those to the saccule 
through the macula cribrosa media. Finally, through the fourth 
macula cribrosa, passes the twig of the small branch of the 
cochlear nerve. The scala vestibuli of the cochlea begins on the 
anterior apex of the vestibule. 

The outer wall of the vestibule is interrupted by the fenestra 
ovalis, but it is so completely and smoothly closed by the base 
of the stapes bone, that the inner surface of this wall of the ves- 
tibule appears even. On the inner wall are two depressions, 
called respectively the recessus sphsericus and the recessus 
ellipticus. A minute elevation between them is called the crista 
vestibuli. 

The crista vestibuli runs above into the pyramidal elevation 
— pyramis vestibuli ; below it divides into two branches, which 
enclose a space called recessus cochlearis. 

Just above the recessus ellipticus opens the ampulla or flask- 
like orifice of the anterior vertical semi-circular canal. The 
recessus ellipticus is partly bounded below by a shallow furrow, 
sinus subciformis. The two vertical canals open at the junction 
of the posterior and inner wall. On the same line, but a little 
higher in the middle of the posterior wall, is the posterior open- 
ing of the horizontal semi-circular canal. The lower opening of 
the posterior vertical canal is in the angle formed by the poste- 
rior, lower, and inner wall of the vestibule. The anterior am- 
pulla of the horizontal canal lies on the outer wall between the 
fenestra oValis and the ampulla of the anterior vertical semi- 
circular canal. 

THE SEMI-CIRCULAR CANALS. 

The semi-circular canals are half -elliptical or C-shaped canals 
which proceed from the vestibule and return to it again. They 
are three in number. The horizontal lies with its convexity 
directed laterally. The other two are vertical in position, form- 
ing a right angle with each other. The two openings of the 
anterior vertical semi-circular canal are near each other and at 
about the same height. The openings of the posterior vertical 



572 



SEMI-CIRCULAR CABALS. 



canals are above each other. The horizontal canal is surrounded, 
as it were, by the two vertical ones. 

There are considerable variations in different individuals, in 
the length and curvature of the semi-circular canals, yet the 
general shape of these parts remains the same. 




Fig. 119. — Section of Temporal Bone of Right Side through the Cochlea (anterior view, 
actual size). 1, Mastoid cells; 2, internal auditory canal; 3, modiolus and lamina spiralis; 
4, cochlea ; 5, superior semi-circular canal ; 6, horizontal semi-circular canal. 

The length of the anterior vertical canal, measured on the 
convex border, with the ampulla and the common crus, is about 
f of an inch ; that of the posterior is \^ of an inch, of the horizon- 
tal \ of an inch. The part common (canalis communis) to the 
two vertical canals is from -fa to -J- of an inch in length. The 
diameter in a grown man varies from ^ to T \ of an inch. 





Fig. 120. — Osseous Cochlea and Semi- 
circular Canals, with Stapes Bone. Left 
Ear of Adult (after Riidinger). 



FiG. 121.— Right Osseous Vestibule, 
Semi-circular Canals, Cochlea, and Ossi- 
cula Auditus of Newly Born (after Rii- 
dinger). 



Wharton Jones makes their calibre about one-twentieth of an 
inch in a direction from the concavity to the convexity of their 
curve. 

Since the semi-circular canals all open at both ends into the 
vestibule, there would be six orifices were not one of the orifices 
common to two of the canals. There are, consequently, five. 
These openings are called ampullae (flasks) from their shape, and 
are more than twice the diameter of the tubes. The inner 



SEMI-CIRCULAR CANALS. 



573 



extremity of the superior vertical canal has a common open- 
ing into the vestibule with the posterior vertical. 




Fig. 122. — The Right Osseous Labyrinth of a Newly Born Subject opened on its Posterior 
Surface (after Rudinger). 1, Cochlear fenestra ; 2, the osseous spiral ; 3, the osseous spiral 
canal of the cochlea — canalis spiralis cochleae — divided by the spiral into two parts, scalae, or 
stairways, the lower the scala tympani, the upper the scala vestibuli ; 4, the basis of the inter- 
nal auditory canal, with the entrance to the Fallopian canal and the maculae cribrosse. The 
latter receive the fibres of the auditory nerve, and the vessels entering with it into the laby- 
rinth; 5, the osseous vestibule, opened on its posterior wall; 6, the posterior semi-circular 
canal ; 7, the upper semi-circular canal ; 9, horizontal semi-circular canal. 

According to Henle/ in the later years of life the semi-cir- 
cular canals increase in length ; the horizontal canal increases 




Fig. 123. — Section of Right Temporal Bone, showing Osseous Semi-circular Canals (actual 
size). 1, Internal auditory canal; 2, superior semi-circular canal; 3, external semi-circular 
canal ; 4, posterior semi-circular canal. 

the most, and the anterior vertical the least. The canals also 
increase very slightly in width; about 0.7 mm. according to 
Hyrtl. 

THE COCHLEA. 

This part of the internal ear is so named from its resemblance 
to a common snail ; a resemblance which is very marked. It is 
one of the most remarkable instances in the whole body of the 
compact packing of very important parts. 



Lehrbueli, p. 7(52. 



574 



COCHLEA. 



The osseous cochlea lies in front of the vestibule, and behind 
the carotid canal, and forms the promontory by pressing out, as 
it were, the bone toward the tympanic cavity. Inward it strikes 
upon the blind end of the internal auditory canal. The cochlea 
is aptly compared to a tube tapering toward one extremity 
where it ends in a cul-de-sac, and which is coiled like the shell 
of a snail round an axis or central pillar. Then we must sup- 
pose this tube divided into passages by a thin partition running 
throughout its length, and spirally around its axis. 

The tube of which the cochlea is formed — the canalis spiralis 
cochleae, is about an inch and a half long, about one-tenth of an 
inch in diameter at its commencement, and about one-twentieth 
at its termination. It makes two turns and a half turn, in a di- 




a c Is 

Fig. 124.— Osseous Cochlea (Right) of the Newly Born, opened from the Outer Surface 
(after Henle). s v, Scala vestibuli ; s t, scala tympani ; I s, lamina spiralis ; c s, crista 
semilunaris; a c, inner opening of the aqueductus cochlea; c m, canalis centralis; s m, 
canalis spiralis modioli. 

rection from below upward, from left to right in the right ear, 
and from right to left in the left ear. The apex of the coil is 
directed forward and outward. The base of the spiral tube runs 
into the vestibule. The cul-de-sac at the apex forms a kind of 
vaulted roof called the cupola. 

The first turn of the cochlea has a circular sweep of a quarter 
of an inch, and is wider than the rest. It is separated from the 
second turn by a soft bony substance, which extends a little 
way between the second and third. The axis is composed of 
the internal walls of the tube of the cochlea and the central 
space circumscribed by their turns, in which space are the fila- 
ments of the cochlear nerve running in small bony canals. The 
axis is about one-seventh of an inch in thickness at the first turn, 



COCHLEA. 575 

but it becomes thinner from the second turn, on to its termina- 
tion. The axis terminates within the last half coil or cupola, in 
a delicate bony lamella, which resembles the half of a funnel, 
divided longitudinally, and called the infundibulum {funnel). 
Wharton Jones compares the appearance of the axis of the 
cochlea after the outer walls have been removed, to the ordinary 
pictorial representations of the tower of Babel. 

The cavity of the cochlea is divided into two parts or pas- 
sages, called scalce, by a thin osseous and membranous spiral 
lamina, lamina spiralis ossea. The lower one communicates 
with the cavity of the tympanum through the fenestra rotunda, 
the upper with the recessus hemisphsericus (see Fig. 118, of the 
vestibule). The former space is therefore called the scala tym- 




FlG. 125. — Section through Cochlea and Vestitmle (left side, actual size. From Professor 
Darling's museum). 1, Carotid canal ; 2, broken styloid process ; 3, first turn of cochlea ; 4, 
vestibule ; A, A, superior semi-circular canal ; B, B, external semi-circular canal ; C, aqua> 
ductus Fallopii ; D, auditory nerve channel. 

pani, the latter scala vestibuli. In the scala tympani, just 
above the membrana tympani secondaria, which closes the fen- 
estra rotunda, is an opening, called the entrance of the aque- 
duct to the cochlea. The two scalae communicate at the apex 
of the cochlea by a common opening called the helicotrema (a 
twisted foramen). This communication exists in consequence 
of the want of a lamina spiralis in the last half coil of the 
canal. 

Two very small canals called aqueducts open by one ex- 
tremity into the labyrinth, and by the other on the surface of 
the petrous portion of the temporal bone. 



576 



MEMBRANOUS LABYRINTH. 



PERIOSTEUM OF THE LABYRINTH. 



The periosteum that covers the walls of the osseous canal 
is, with the exception of that on the outer wall of the cochlea, 
very delicate. Henle ' compares the periosteum of the labyrinth 
to one of the parts of the choroid, because it is strewn with nu- 
cleated pigment cells. There are also calcareous deposits. It 



n,i '^ 



£'*A 



V«, 








Fig. 126. — Periosteum of the Labyrinth Fig. 127.— Periosteum of the Outer Wall of 
(after Henle). the Cochlea (after Henle). 

is very difficult, according to Henle, to separate the periosteum 
of the labyrinth, without also detaching bits of bone. The 
periosteum is abundantly supplied with blood-vessels. 



THE MEMBRANOUS LABYRINTH. 

Utricle and Membranous Semi-circular Canals. 

The utricle is an elliptical tube, situated on the median wall 
of the vestibule. Its longest diameter corresponds to the height 
of the vestibule. By means of a fine vascular and nervous net- 
work, and a very delicate connective tissue, it is fastened to the 
recessus ellipticus of the vestibule. 

The membranous semi-circular canals are but the lining of 
the osseous canals, and, of course, of the same shape. The 
membranous canals open into the utriculus with five openings, 
just as do the osseous tubes in the vestibule. At the ampullae, 
the membranous canal fills up the osseous very completely ; but 
there is some space between the other parts. The walls of these 



1 Lehrbucli, p. 774. 



MEMBRANOUS LABYRINTH. 



577 




structures are transparent, as clear as water, and of great deli- 
cacy. After the endolymph is removed, they fall together and 
arrange themselves in rigid folds. There is, 
however, a point that is firmer, called the 
macula acustica, situated on the median 
wall of the utricle, where a twig of the 
auditory nerve reaches this wall. The por- 
tion of the ampulla that contains the termi- 
nation of the nerve, and which is detected 
by the naked eye as a whitish-yellow spot, 
is also of firmer consistency. This point is 
called the crista acustica by Max Schultze. 
It comprises about one-third of the wall of 
the ampulla. It is sometimes surrounded by a pigmented line 
and also receives nerve-twigs. 

The wall of the membranous semi-circular canals is from 
0.02 mm. to 0.03 mm. in thickness, and is composed of various 
layers. 

The membrana propria is of reticulate and nuclear fibrous 
tissue, of which the periosteum also consists. It is perforated 



Fig. 128.— Utricle and 
Membranous Semi- circular 
Canals of the Left Side. 




Fig. 129.— A Piece of the Wall of the Utricle, with the Otoliths (after Henle). 

by blood-vessels. There is a basal membrane next the mem- 
brana propria, and on the inner surface pavement epithelium. 

The macula and crista acustica that have been mentioned, 
are thickenings of the membrana propria, caused by the min- 
gling of connective tissue, and the ending of the nerves. 

The otolith of the utriculus of the mammalia is a smooth, 
irregularly demarcated and uneven mass of chalky white pow 
der. It was called otoconia by Breschet, ear-sand by Lincke, 
37 



578 DUCTUS COCHLEAEIS. 

and ear-crystal by Huschke. The powder is held together by 
an almost mucous substance, and consists of crystals of carbo- 
nate of lime, of varying shape and size. The largest are only 
0.01.2 mm. long and 0.008 mm. broad. They are too small to 
allow the crystal form to be recognized. Henle says it is un- 
known how the otolith is fastened on to the wall of the utricle. 



SACCULE. 

The saccule is of the shape of a broad flask with narrow 
neck. Its body (about -^ inch in diameter) lies in the recessus 
sphsericus of the vestibule. The neck (canal is reunicus, about 
s 1 - inch long and y^ inch in diameter) of this bottle or flask pro- 
ceeds from the lower wall, downward and backward, and sinks 
into the upper wall of the vestibular end of the ductus cochle- 
aris, at nearly a right angle, so that a blind sac is formed at the 
junction of the two parts. Henle compares it to the passage of 
the oesophagus into the stomach, and of the small intestine into 
the ccecum. 



THE DUCTUS COCHLEAEIS (LAMINA SPIEALIS MEMBEAXACEA OE THE 

OLD AXATOILISTS). 

The ductus cochlearis begins with the blind sac in the vesti- 
bule that has been described, and passes through the whole 
cochlea to the apex, in which it ends again as a blind sac. The 
lower end rests in the recessus cochlearis. and the upper in the 
cul-de-sac of the cupola. The ductus cochlearis is attached on 
one side to the lamina spiralis ossea, and on the other to the 
outer wall of the osseous cochlear canal. On a transverse sec- 
tion the ductus cochlearis is seen to be triangular in shape, and 
has, of course, three walls or sides. Two of these walls diverge 
from the edges of the lamina spiralis, and the other corresponds 
to the portion of the cochlear wall, between which the insertion 
of the two others is made. The lower wall of the ductus coch- 
learis, which is turned toward the scala tympani. is called the 
tympanal : the upper, which separates the ductus cochlearis 
from the scala vestibuli, is called the vestibular wall. 

On the osseous border of the lamina spiralis is a soft struc- 
ture, only to be seen in .the uninjured specimen of the cochlea, 
which lengthens the lamina spiralis toward the calibre of the 
ductus cochlearis. It is called by Henle the limbus laminae spi- 
ralis. It is developed from the periosteum of the lamina spi- 
ralis. This structure gradually decreases in breadth and height 
from the base to the apex of the cochlea. The edge of the osse- 



DUCTUS COCHLEARIS. 579 

ous lamina recedes more and more at the same time from the 
free border of the limbus. This free border becomes a furrow, 
called by Huschke the sulcus spiralis, having, of course, two 
lips. The upper lip is the labium vestibulare ; the lower, the 
labium tympanicum. The vestibular wall of the ductus cochle- 
aris passes off from the upper surface of the lamina spiralis in a 
line nearly corresponding to the inner attachment of the limbus 
laminae spiralis, so that the latter is almost completely drawn 
into the ductus cochlearis. 

The upper surface of the vestibular lip of the limbus lamina 
spiralis is covered by striae, which on front view resemble the 
anterior surface of the incisor teeth, and hence Huschke calls 
them the auditory teeth. These furrows, or striae, are filled by 




Fig. 130. — Transverse Section of a Cochlear Spiral, from a Cochlea softened in Hydro- 
chloric Acid (after Henle). The dotted lines indicate sections of the membrana tectoria and 
the auditory rods ; I s. lamina spiralis ; I I s, limbus laminae spiralis ; s w, scala vestibule ; s t, 
scala tympani ; d c, ductus cochlearis ; I s p, ligamentum spirale ; v, membrana vestibularis ; 
6, membrana basilaris ; e, outer wall of ductus cochlearis ; *, bulging of this wall. 

small rounded cells. Their number may run as high as 2500. 
The limbus is composed of connective tissue, running in a radi- 
ate direction in the furrows, or striae ; beneath these furrows the 
connective tissue is reticulate. 

Henle compares the labium vestibulare to a roof over the 
sulcus spiralis, and the labium tympanicum to a floor. Within 
the labium tympanicum run very fine nerve-fibres from the tis- 
sue of the auditory nerve to the ductus cochlearis. The labium 
tympanicum consists of two layers, which include the nerve- 
fibres between them, and then unite beyond it in a sharp border. 
from which the membrana basilaris proceeds. This membrana 
basilaris, according to Henle, appears as a process of the upper 
layer of the labium tympanicum. There is, however, a struc- 
ture between them, which corresponds to the periphery of the 
nerve bundles. 



580 COETl'S ORGAN — DUCTUS COCHLEARIS. 

On the outer portion of the upper surface of the labium tym- 
panicum are four radiate striae, which Henle considers as marks 
of the nerve bundles running on the lower surface of this layer. 
At the periphery of these there are other openings. 

The membrana vestibularis is attached to the beginning of 
the upper border of the ridge of the spiral and to the outer 
cochlear wall. There are three layers in this membrane, which 
by Kolliker is called Reissner's membrane. It is epithelial tissue, 
which in embryonal life seizes upon the vestibular side of the 
cochlear canal. This membrane has a number of blood-vessels. 

The membrana basilaris is well shown in the preceding figure, 
and being the part upon which rests the organ of Corti, has at- 
tracted very much attention from anatomists. It is a continua- 
tion of the labium tympanicum. It gradually increases in breadth 
from the base to the apex, in the same proportion that the lamina 
spiralis with its limbus decreases in size. Its breadth in the 
newly born, in the middle of the first turn or coil of the cochlea, 
is 0.17 mm.; at the end of the second, 0.45. This space is divided 
into two parts or zones. The inner was called by Kolliker, the 
habenula tectu, and the outer by Todd and Bowman, the zona 
pectinata. Henle gives the two parts the simple names of inner 
and outer zone. On the inner zone are found the structures 
making up what is known as Corti's organ, from their discov- 
erer, Marchese Corti. 1 The outer zone is rather broader than the 
inner. 

The basis of the membrana basilaris is a structureless mem- 
brane. On the outer zone especially are peculiar knobby points. 
Upon this structureless membrane are the parts known in their 
totality as Corti's organ. The fibres of this structure are ar- 
ranged along the whole length of the membrana basilaris. 
There are spaces between them, so that they have a certain 
resemblance to the keys of a piano. 

The ligamentum spirale is the means of attaching the mem- 
brana basilaris to the outer wall of the cochlear canal. The 
fibres of which it is composed are like those of periosteum. 

The cavity of the ductus cochlearis is divided into parts by a 
membrane running parallel to the membrana basilaris. The 
upper part is filled with endolymph, the lower contains what 
Henle calls the terminal auditory apparatus. The membrane 
which divides the ductus cochlearis into two parts is called the 
membrana tectoria by Claudius, but Corti's membrane by Kol- 
liker. The membrana tectoria is divided into three zones. The 

1 Corti was formerly prosector to Professor Joseph Hyrtl, and made the first exact 
microscopic examination of the lamina spiralis ossea, and membranacea. 



CORTl'S RODS. 581 

middle zone is the denser; the inner is structureless and has 
numerous openings. The outer zone is made up of a very fine 
and friable network. It is probable, according to Henle, that 
the membrana tectoria is firmly fastened, and that it is not 
possible for it to press closely upon the parts covered by it. 

TERMINAL AUDITORY APPARATUS. 

The most important, physiologically speaking, of this termi- 
nal apparatus are the auditory rods, called also Corti's teeth, or 
Corti's fibres. They are arranged in regular order, very like the 
cords, hammers, or keys of a piano. They are shaped like a 
Eoman S, having slender cylindrical bodies and broad ends con- 
taining granular protoplasm. There are two rows of these fibres, 
an inner and an outer. The inner rods arise from the membrana 




Fig. 131.— From the Terminal Auditory Apparatus of a Cat (after Henle). /, Outer ends of 
the inner fibres ; e, outer fibres ; 3, outer covering cells ; 4, epithelial cells. (500 x 1.) 

basilaris, on which their internal extremities are fastened, more 
or less abruptly, toward the membrana tectoria, without, how- 
ever, being united to the latter. The outer rods or fibres join, 
with their inner extremities, the outer end of the inner fibres. 
Their external terminations rest on the membrana basilaris. 
There are two varieties of the inner row of fibres or rods ; one is 
smooth and elliptical in shape, the other cylindrical and broader 
at each end. 

The outer row of rods is cylindrical in shape, and they stand 
at a greater distance apart than the inner. The estimated num- 
ber of inner pillars is C000, of the outer 4500. The inner row of 
fibres is always shorter than the outer. They join together and 
form a roof over the inner zone of the membrana basilaris. The 
base of this roof is 0.1 mm. in breadth. The structure of these 
rods, as shown by the action of reagents, is a tissue as hard as 
cartilage. 



582 AUDITORY NERVE. 

Henle calls the terminations of the two rows of rods upon the 
membrana basilaris, the lower extremities ; and the extremities 
which join to make the roof, the upper extremities. The cells 
found in the ductus cochlearis, auditory cells, are nucleated, 
round, and cylindrical. A layer of them covers the sulcus spi- 
ralis, Reissner's membrane, and the outer wall of the ductus 
cochlearis. Upon the inner pillars lies a single row of conical 
cells with large nuclei. They send processes into the rows of 
small cells lying next toward the sulcus spiralis, the granular 
layer. The ends turned toward the heads of the rods bear tufts 





2 4 ** 

Fig. 132. Fig. 133. 

Fig. 132.— Profile View of Outer and Inner Rods. 

Fig. 133. — Membrana Basilaris (&), with the terminal nerve-fibres {ri) and the inner and 
outer rods ; and 1 , inner ; 2, outer floor cells ; 4, attachment of the roof cells ; **, epithelium. 

of stiff immovable cilia. These cells are called inner hair-cells. 
Their number is computed at 3300. On the outer rods lie three 
or four rows of double nucleated cells, connected by slender pro- 
cesses to the membrana basilaris and membrana reticularis, and 
bearing also tufts of cilia. Their number is computed at 18,000. 
The cilia of the cells are received in the lamina reticularis in 
corresponding rows of openings. Waldeyer regards the cells, as 
also the rods of Corti, as epithelial structures. Henle describes 
another layer of cells lying on the membrana basilaris as floor 
cells. 

The membrana reticularis is the second of the component 
parts of the terminal auditory apparatus. It arises from the 
articulation of the rods or fibres, and extends to the outer wall 
of the cochlea parallel to the lamina basilaris. It is supposed to 
be a ligament to bind the rods together. The tissue of the lam- 
ina reticularis is not less firm than that of the rods, but it is 
delicate. 

AUDITORY NERVE. 

The Auditory Nerve {Nervus acusticus). — The auditory 
nerve, or portio mollis (soft part of the seventh nerve), is the 
nerve of the sense of hearing, and is distributed exclusively to 
the internal ear. The auditory nerve arises by two roots in the 



AUDITORY NERVE. 



583 



medulla oblongata. One ganglionic nucleus of origin is in the 
floor of the fourth ventricle. The other is in the crus cerebelli 
ad-medullam. The roots of the nerve are connected, on the 
under surface of the middle peduncle, with the gray substance 
of the cerebellum, with the flocculus, and with the gray matter 
at the border of the calamus scriptorus. The nerve winds 
around the restiform body, from which it receives fibres, and 
passes forward across the posterior border of the crus cerebelli, 
in company with the portio dura, or facial nerve, from which it 
is partly separated by a small artery. It then passes into the 
meatus auditorius internus, where some minute filaments con- 
nect them together. 

4 3 




Fig. 134. — Expansion of the Right Cochlear Nerve, seen from the Base of the Cochlea, 
from a Labyrinth softened in Hydrochloric Acid (after Henle). 1, The branches entering 
through foramina ; 2, twig passing into the modiolus ; 3, network in the osseous lamina spi- 
ralis ; 4, network on its border ; I £, labium tympanicum ; z i, zona interna ; z e, zona externa 
of the membrana basilaris ; I s, ligamentum spirale. (15 x 1.) 

The auditory nerve is remarkable for the delicacy of its 
structure, which caused the older anatomists to give it the 
name of portio mollis. It has only a very thin neurilemma. 

At the bottom of the meatus the facial nerve enters the Fallo- 
pian canal, the auditory divides into two branches, vestibular 
and cochlear. 

The cochlear nerve gives off a small branch, which passes to 
the vestibular extremity of the ductus cochlearis, and through 
the fourth macula cribrosa, to the partition wall of the two sac- 
cules in the vestibule. From the trunk of the nerve a number 
of fine twigs arise, which pass through foramina direct to the 
lamina spiralis of the lower coil of the cochlea. The remainder 
of the cochlear nerve enters the modiolus, and is divided into 
anastomotic divisions. The fibres become separated from the 



584 AUDITOKY NEKVE. 

trunk in a line corresponding to the course of the canalis spi- 
ralis modioli, and permeate this canal. Here, by the addition 
of ganglion cells, they become gangliose strise, and finally end, 
at almost a right angle to the trunk, in the osseous lamina spi- 
ralis. 

The vestibular nerve, after a slight gangliose expansion, 
divides into three branches : 

1. Superior.— This passes through the macula cribrosa supe- 
rior, and ends by three branches to the utricle and ampulla of 
the superior vertical and horizontal semi-circular canals. 

2. The middle passes through the macula cribrosa media to 
the saccule. 

3. The inferior passes through a bony canal of its own to 
the ampulla of the inferior vertical semi-circular canal. The 
terminal nerve-fibres pass from the lamina spiralis through fine 
holes in the labium tympanicum, and in the membrana vesti- 
bularis into the ductus cochlearis. 

They run in a radiate direction, pass through the granular 
layer, where some end in inner hair-cells and others run be- 
tween the rods of Corti and across the tunnel formed by them, 
to end in outer hair-cells. There are probably other nerve-fibres 
running in a spiral course among the granular layer and the 
outer hair-cells. 

Todd and Bowman regard the vestibular nerve as direct pro- 
longation of the white matter of the brain. 

In the internal auditory canal, the portio mollis forms a con- 
nection with the portio dura by means of a few fascicles of 
fibres, which constitute what Wrisberg called the "portio inter- 
media." It is not decided whether the connecting link proceeds 
from the auditory to the facial nerve, or from the latter to the 
former. Todd and Bowman believe it probable that the facial 
nerve sends some filaments to the blood-vessels of the labyrinth 
and the muscular structure of the internal ear. 

The internal auditory canal (meatus audit orius internus) 
begins at about the centre of the petrous portion of the temporal 
bone by a large orifice with smooth rounded edges, and runs 
directly outward about one-eighth of an inch to end in a blind 
fossa. 

There are four depressions in the fossa. These are perfo- 
rated by fine foramina, through which the fibres of the acoustic 
nerve enter the labyrinth. Three of them correspond to the 
maculce cribrosa. The fourth lies opposite the base of the coch- 
lea. It is spiral-shaped, has spiral-shaped openings, and is called 
the tractus spiralis foraminosus. 



BLOOD-VESSELS — PHYSIOLOGY, 585 



BLOOD-VESSELS. 

The blood passes to the internal ear through the auditiva 
interna artery, which is a branch of the basilar, according to 
Hyrtl. The basilar comes from the vertebral and the vertebral 
from the subclavian. After the internal auditory artery has 
entered into the meatus auditorus internus, it divides into a 
vestibular and cochlear branch. The cochlear branch divides 
in numerous branches which pass through the foramina of the 
tractus spiralis foraminosus into the modiolus, and then go on 
between the layers of the lamina spiralis, and are finally lost in 
the spirals of the cochlea. The vestibular artery passes through 
the posterior wall of the vestibule in numerous fine twigs to the 
soft structures of the vestibule and semi-circular canals. The 
stylo-mastoid artery is said to give several small branches to 
the labyrinth. It is important to observe the fact to which Von 
Troltsch calls attention — that the blood-supply of the labyrinth 
and of the middle ear are nearly separate and independent of 
each other. This may explain the relative infrequency of the 
extension of disease of the middle ear to the internal ear. 



THE PHYSIOLOGY OF THE INTERNAL EAR. 1 

The vibrations of the atmosphere are conveyed through the 
ossicles and fenestra ovalis to the perilymph of the labyrinth. 
They pass as waves over the vestibule, semi-circular canals, and 
other parts of the labyrinth, and are there transmitted to the 
endolymph. A vibration passes from the vestibule into the scala 
vestibuli of the cochlea, and passing down the scala tympani 
ends as an impulse against the fenestra rotunda. The variations 
in pressure of the fluid of the labyrinth, which is surrounded by 
particularly firm bony walls, thus excited by the motions of the 
foot-plate of the stapes bone, are compensated for by a move- 
ment of the membrane of the fenestra rotunda. The helico- 
trema, the small opening through which the two scalae of the 
cochlea communicate, allows the membrana basilaris with the 
parts lying upon it (Corti's organ) to be set in motion. Buck's in- 
vestigations lead him to believe that "no communication exists 
between the two scala? in the immediate vicinity of the cupola." 
unless the opening spoken of so vaguely by the authors, be micro- 
scopic in size." This negative assertion has not been confirmed 



1 Foster: Text-Book of Physiology. Hartmann: Lehrbncli. Hensen: Haiulluu-h 
der Physiologic von Hermann, Leipzig, 18b0. Pulitzer ; Lekrbuoh. 
9 Treatise on the Ear, p. 12. 



586 



PHYSIOLOGY OF IXTERXAL EAR. 



by other anatomists, and the opening is still described by those 
who have written since Buck's statement was made. 

The exact function of the individual portions of the labyrinth, 
in spite of the investigations of the physiologists, is not yet posi- 
tively settled. According to Helmholtz, the vestibule and am- 
pullae are adapted to the perception of noises, irregular vibra- 



External 



Tympanum 

or middle 

ear. 



Labyrinth or internal 
ear. 




(Acoustic 
1 nerve. 



tube 



Fig. 135. — A diagram designed to illustrate the Physiology of the Labyrinth (Professor A. 
L. Ranney). 1, External auditory canal; 2, the membrana tympani; 3, the tympanic cavity 
with its chain of bones connecting 2 with 4; 4, the fenestra ovahs ; 5, the utricle, communi- 
cating with the semi-circular canals (11, 12, and 13) ; 6, the saccule, communicating with the 
scala vestibuli of the cochlea (s v) ; 7, the ampullae ; 8, the fenestra rotunda, opening from 
the scala tympani (s t) into the cavity of the tympanum (3) ; 9, the Eustachian tube, allowing of 
the entrance of air from the pharynx into the tympanic cavity; 10, the internal auditory 
canal, transmitting the acoustic nerve ; 11, 12, and 13, the semi-circular canals; 14, the open- 
ing of the mastoid cells into the tympanic cavity (3) and the external auditory canal (1) ; s v, 
the scala vestibuli of the cochlea ; s t, the scala tympani of the cochlea ; c, the cupola. 



tions, while the cochlea perceives periodic vibrations — tones. 
Helmholtz also showed that it is probable, that the part of the 
cochlea near the fenestra rotunda vibrates more easily to high 
notes, or those with many vibrations in a second, while that in 
the cupola vibrates more readily to low tones. The membrana 
basilaris of the cochlea increases in width from the lowest wind- 
ing of the cochlea to the cupola. Helmholtz says that the mem- 
brana basilaris has a system of cords corresponding to its stripes, 
of which, for certain tones, only a limited number vibrate. The 
perception of the high tones is caused by the lower section of the 
membrana basilaris, and of the low or deep ones by the superior 



PHYSIOLOGY OF INTERNAL EAE. 587 

parts. This corresponds with the clinical experience, that pa- 
tients deaf from exudations in the middle ear, encroaching upon 
the labyrinth, hear low tones, when they cannot at all perceive 
high ones. The case of atrophy of the acoustic nerve in the 
first whorl of the cochlea, reported by Moos and Steinbrugge, 1 is 
also strong evidence in support of this view. The patient was 
sixty-three years old. His ears were examined fourteen days be- 
fore his death. He suffered from loss of hearing and constant 
tinnitus. The loss of hearing is said to have occurred suddenly. 
He could not hear the voice at all on the right side, and 3 metres 
on the left. He died of carcinoma of the right anterior central 
convolution, he also had carcinoma of the stomach. In the ear 
was found, as has been said, atrophy of the nerve-fibres of the 
first cochlear whorl. The external ear, and middle ear, except 
the junction of the stapes with the vestibule, were in a normal 
condition. There was rigidity of the articulation. There was 
also sclerosis of the cells of the mastoid process. The patient 
during life was found very deficient in the power of hearing high 
notes. It has been shown by Moos and others, that the power 
of hearing conversation well, involves capability of hearing 
high notes. 

Although Helmholtz's theory of the function of the cochlea 
is not everywhere positively accepted, the weight of evidence 
seems to be in favor of the view, that it has a higher function 
than the vestibule, and that by it an analysis of tune is made. 
The place that Corti's rods long held as the terminal organs of 
hearing must, however, be abandoned, for Hasse found in birds 
that possessed the power of hearing musical tones and speech, 
that while Corti's cells were developed the rods of Corti were 
wanting. 

The view that the cochlea alone is for the perception of tone, 
is put somewhat in doubt by Ranke's and Hensen's experi- 
ments. On microscopical examination of living heteropodes, 
Ranke found the auditory cilia vibrating rapidly and moving 
toward the otoliths, in the aural vesicle. Hensen, in experiment- 
ing upon crabs, showed that when tones were produced a certain 
number of cilia vibrated to certain tones. 

The semi-circular canals seem to have nothing to do with th 
hearing function, but since the experiments of Flourens it is gen- 
erally, although not universally, accepted that they are the parts 
chiefly concerned in maintaining the equilibrium of the body. 

The greater number of authorities regard them as the organ 
of the sense of equilibrium, but this view is not everywhere 



e 



1 Zcitsclirift fur Ohronhoilkunde, Bd. X., p. 1. Archives of Otology, vol. x.. p. 1. 



588 AUDITORY NERVE. 

accepted. Bottcher, on the basis of experiments like those of 
Flourens, believes that the symptoms seen after injury of the 
semi-circular canals are due to a simultaneous injury of the cere- 
bellum. Moos agrees with this author from clinical observa- 
tions made upon patients. In accordance with the views of 
Lussana and Berthold, he thinks that the disturbances of co- 
ordination after injury of the semi-circular canals are excited by 
a reflex transmission of the irritation from the ampullar nerves 
to the cerebellum. 

Hogyes, quoted by Politzer, 1 says that the terminations of 
the auditory nerve in the vestibule are a peculiar apparatus to 
regulate the movements of the eyes and probably also those of 
the muscles for the preservation of the equilibrium of the body. 
Lussana separated the semi-circular canals, without at the same 
time irritating the nerves of the ampullae or vestibule, and even 
after the labyrinth was entirely destroyed, no disturbances of 
co-ordination were seen. Politzer's experiments with the supe- 
rior semi-circular canal, showed that the fluid of the labyrinth 
could be influenced by pressure or exhaustion of the air in the 
auditory canal or tympanum. A manometric tube was placed 
in the superior semi-circular canal after having been filled with 
fluid. On pressure from the canal or tympanum the fluid arose, 
and on exhaustion it sank. These experiments were verified and 
amplified by Helmholtz and others. 



Sensory Centre of Auditory Nerve. 

Ferrier 2 finds the sensory centre of the auditory nerve in the 
temporal lobe of the cerebrum. Its anatomical connection with 
the nuclei and roots of the nerve has not been proven. Ferrier 
observed on electric irritation of the superior temporal convo- 
lution on the exposed brain of cats, dogs, and monkeys, a sud- 
den elevation of the auricle of the opposite side, and on destruc- 
tion of the temporal lobe deafness of the opposite ear. Munk, 3 
quoted by Politzer, got the same results, by experiments on 
dogs. He thinks they indicate a decussion of the fibres of the 
auditory nerve in the brain. 

Munk believes, as quoted by Politzer, that if the parts of the 
temporal lobe, termed "hearing spheres," were removed, and 
the ear of the same side destroyed, the animal would be deaf. 
Munk also believes that the posterior part of the hearing sphere 

1 Text-book, translation, p. 682. 

2 The Functions of the Brain, p. 171. New York, 1876. 

3 Text-hook, p. 684. 



DIRECTION OF SOUND. 589 

perceives low tones, and that the anterior section in the neigh- 
borhood of the fissure of Sylvias is for the perception of high 
tones. 



Determination of Direction of Sound. 

It was formerly supposed that the direction of sound was 
determined by the aid of the semi-circular canals. It seems, 
however, from clinical experience, that the direction of sounds 
is determined by the two ears acting together, for many pa- 
tients have assured me that simultaneously with the loss of one 
ear, they have lost in great if not complete measure, the ability 
to tell from whence sounds came. It is probable that the two 
ears are not necessary for the determination of the quality of 
tones. If this be true, there is no advantage in binaural stetho- 
scopes, other than that which may be gained by having both 
ears closed to distracting external sounds. 












CHAPTER XXL 

DISEASES OF THE INTERNAL EAR 

Difficulty in Diagnosis. — Clinical and Pathological Advances — I'iiierentiation be: - 
Diseases of Middle and Internal Ear. — Nervousness and Nervous Deafr — -. — 
Symptoms f Pri— aiy Disease :: the Cochlea.— Acoustic Neuritis — Atrophy of 

the A::^s:i: >~erve. — Cases. — The Tuning-Fork in D: ^msis — I't-::.:- :■: Cer- 
tain Tones. — Doable Blearing. — Electricity. — Syphilitic Dis^asr of the Cochlea. — 
kli::s. — Gases. 

"With our present knowledge, any discussion of the diseases of 
the internal ear, is based upon a less secure foundation of patho- 
logical and clinical experience, than is the case in the consi l- 
eration of diseases of the external and middle ear. Until the 
greater questions in rhe physiology and anatomy of the laby- 
rinth are positively settled, we cannot be sure of our classifica- 
tions of disease. But the great barrier to our accurate knowl- 
edge of diseases of the labyrinth — such a knowledge as we have 
in studying the affections of the optic nerve and retina — is found 
in the fact, that the otoscope as yet only enables us to see the 
tympanum and mouth of the Eustachian tube, while the oto- 
liths, the semi-circular canals, and the whorls of the cochlea 
remain hidden by an apparently impenetrable bony ease. In 
spite of all this, clinical and pathological study, are slowly giv- 
ing us access to what was once as much a maze to the thera- 
peutist, as to the anatomist. A certain class of diseases of the 
internal ear. can now be made out with as much accuracy as 
ases of the heart, lungs, or kidneys. We can. in some in- 
stances, even classify the diseases of the semi-circular canals 
and cochlea, for some of them are to be plainly distinguished. 

In this chapter, then. I shall endeavor to set forth in a simple 
manner, how we may. in many instances, differentiate between 
dis-r. - - : the middle and internal ear. It is not long since the 
average description of diseases of the tympanum and Eusta- 
chian tube, assumed that they belonged to the internal ear. for 
all the parts beyond the membrana tympani were classified as 
internal. It is a great step forward, to have clearly separated 
the middle ear from the labvrinth. the real internal ear. I have 



PRIMARY DISEASE OF AUDITORY NERVE. 591 

no doubt that before many years, medical science will as clearly 
separate the diseases of the two parts as it has its anatomy. 
There is much to be gained in practice, by a careful considera- 
tion of what is already known of the differential diagnosis of the 
diseases of the middle and internal ear, and I shall attempt to 
make this as clear as my experience and deductions from that 
experience, will permit. I wish it to be understood, however, 
that I believe we are but in the infancy of our knowledge of this 
subject. Just as explorations in an hitherto scarcely traversed 
country, have a great attraction for the enthusiastic traveller, 
so I believe, will the medical explorer find very much to interest 
him in the diagnosis of diseases of the labyrinth and acoustic 
nerve, for this field is the ultima Thule of aural territory. 

The affections of the internal ear may be classified in a gen- 
eral way, as follows : Primary and secondary diseases. The 
latter class has been somewhat discussed in the various chap- 
ters on "Diseases of the External and Middle Ear." They are 
generally recognized, and do not often excite discussion. I will, 
however, speak of some of their symptoms again somewhat 
fully in this chapter, after the primary affections have been 
studied. 

Primary affections of the auditory nerve, or what were called 
cases of nervous deafness, were at one time supposed to be very 
common. This was chiefly due to the teachings of Kramer and 
the preceding authors. Wilde and Troltsch, gave us more cor- 
rect notions as to the relative frequency of the diseases of the 
central apparatus, and proved that the diseases of the middle ear 
were more common than those of the labyrinth — that so-called 
nervous deafness was comparatively rare. 

Clinical experience has, however, brought me more and more 
to the conviction, that the rebound from the ideas of Kramer, who 
at one time classified the majority of cases of aural disease under 
the head of nervous affections, to those of Wilde and Troltsch, 
the latter author tracing almost all cases to an inflammation 
of 'the middle ear, has been excessive, and that there is a larger 
proportion of cases, which are primarily affections of the laby- 
rinth than has generally been believed by the profession for the 
past twenty years. 

Before I discuss the symptoms and causes of affections of the 
nerve of hearing, a few words may be proper, as to what in 
general terms is understood by impairment of hearing, depen- 
dent upon disease of the central apparatus, or by nervous deaf- 
ness. 

When a patient is debilitated and unstrung, unsteady in mus- 
cular movement, anxious and despondent, and is at the same 



592 NERVOUSNESS AND NERVOUS DEAFNESS. 

time affected with a chronic affection of the middle ear, he is 
often supposed to have a nervous disease of the ear. It is quite 
doubtful, however, if in such cases the auditory nerve is at all 
affected. There are certainly no symptoms of derangement of 
the auditory nerve, in the general debility, unsteadiness, and 
anxiety that are popularly denominated nervousness. Affec- 
tions of this nerve make the subjects deaf, and sometimes cause 
them to stagger in their gait, but they do not always render them 
nervous or unsteady in the ordinary acceptation of those terms. 
Besides, it cannot be said that nervous people are especially 
liable to deafness from lesions of the labyrinth, any more than 
they are to atrophy of the optic nerve. On this point Mr. Hin- 
ton ' says, that it is difficult for him to accept debility, nervous 
or other, as a cause of nervous deafness. He has not found that 
the cases of deafness which appear to him as properly classed 
among the nervous ones, occur especially in the debilitated. 

With this view I am in full accord. So-called nervous people 
are not especially apt to have a disease of the acoustic nerve, 
but their impairment of hearing often depends upon chronic in- 
flammations of the tympanum, its ossicles, muscles, and lining 
membrane. The nervousness in some instances results from the 
distressing tinnitus, and the impairment of hearing, for there is 
no affliction more depressing than impairment of hearing. There 
are, however, symptoms more or less objective, that enable us 
to diagnosticate with tolerable exactness a disease of the inter- 
nal ear. It is not wholly an undiscovered country. 



PRIMARY DISEASE OF THE COCHLEA OR OF THE TRUNK OF THE 
ACOUSTIC NERVE. 

There is one symptom of this affection that is pathognomonic, 
and that is absolute deafness. There is no disease of the exter- 
nal ear, and none of the middle ear, I think, which will make a 
patient deaf to all sounds. No matter what may be the patho- 
logical condition, how firmly the auditory canals or tympana 
may be plugged, sounds conducted through the bones will still 
be heard ; but when the cochlea and the vestibule with their 
contents are destroyed, no vibrations are perceived, and absolute 
deafness exists. But such cases are very rare. There are very 
few absolutely deaf persons in the world. Hence this pathog- 
nomonic symptom is seldom observed. When it is, of course a 
diagnosis is easily made. But the labyrinth may, I believe, be 
invaded by disease, and even the terminal filaments of the 

1 Nervous Deafness. Reprint from Guy's Hospital Reports, 1867. 



PRIMAEY DISEASE OF INTERNAL EAE. 593 

nerve in the cochlea, or the nerve-trunk itself be diseased, and 
yet very considerable hearing remain. Reasoning by analogy, 
this would appear to be true, for we may have even advanced 
atrophy of the optic nerve and retina, and yet a fair degree of 
vision. It has been too hastily assumed, I think, that because 
considerable hearing power remained, therefore the cochlea could 
not be invaded. We must go much deeper in symptomatology 
than absolute deafness, if we desire to find the causes of disease 
of the acoustic nerve. * 

1. The ability to hear the tuning-fork better and longer 
through the air than through the bones of the head, is a symptom 
of disease of some part of the labyrinth, either of the vestibule, 
the cochlea, or acoustic nerve. But this symptom is not pathog- 
nomonic of primary disease of the labyrinth. It is always found 
when the labyrinth is invaded, but in many instances it is a 
temporary phenomenon dependent upon abnormal pressure ex- 
erted upon the labyrinth by the ossicles or the drum-head. If we 
add to the above symptom the word constantly, so that it shall 
read, the ability to constantly hear the tuning-fork better 
through the air than through the bones, we shall be nearer to 
a definition of a symptom of primary disease of the cochlea. 
Even then we must exclude cases where the pressure has become 
permanent, and where, after all, the disease of the labyrinth is 
secondary to one of the stapes bone, or other part of the tympa- 
num. This much we may say, however, that better aerial than 
bone conduction indicates either primary or secondary disease 
of the central apparatus of hearing. 

2. The ability to hear better in a quiet place, when cdl dis- 
tracting noises are absent, is a symptom of disease of the laby- 
rinth. It must be taken, however, when applied to primary 
disease, with the same limitations as to constancy as the test by 
the tuning-fork. 

3. The ability to hear conversation relatively farther than 
the tick of a tvatch, is also a symptom of disease of the cochlea 
or nerve. These symptoms, namely better aerial than bone 
conduction, better hearing in a quiet place, relatively better 
capacity to hear the human voice than the tick of a watch, 
when found grouped together in the same patient, to my mind 
unmistakably stamp the case as one of disease of the acoustic 
nerve. It will be observed that I have said nothing of vertigo, 
of double hearing, of incapacity to hear one's own voice, which 
are generally considered to be symptoms of disease of the laby- 
rinth. I have purposely omitted any enumeration of these more 
marked symptoms at this point, for I would like to impress 
upon my readers my belief that there is a class of cases of affec- 

38 



594 DIAGNOSIS OF PRIMARY DISEASE OF INTERNAL EAR. 

tions of the cochlea, or vestibule, or trunk of acoustic nerve, 
whether of one or of all, I do not pretend to know, which have 
no very marked symptoms, such as absolute deafness, vertigo, 
or double hearing. I will give instances of these in this chapter, 
and will lay stress upon them, for these cases, if I am right, are 
constantly mistaken for disease of the middle ear. It is from a 
long series of investigations, that I have come to the conclusion 
that such cases are more common than has been before believed. 

I ought also £p say, that in diseases of the labyrinth, noise 
not only impairs the hearing power, but it often also distresses 
and annoys the patient, whereas persons who are very deaf 
from disease of the middle ear, are delighted when they can be 
in a noise. 

To repeat, whenever the following train of symptoms occurs 
in a case of impairment of hearing, I believe we may conclude, 
in the light of our present knowledge, that we have to do with 
disease of the internal ear. 

1. Tuning-fork C 2 is heard better through the air. 

2. Hearing is better in a quiet place. 

3. Conversation is heard relatively better than a watch. 

4. Noise is annoying to a more marked degree than is usual 
to people tvho hear ivell, or to those who are deaf from disease of 
the middle ear. 

5. Inflation of the tympanum renders the hearing worse. 

To make a clear diagnosis these symptoms must exist to- 
gether. I will not deny that some cases with this chain of symp- 
toms, may be secondary affections of the sensory apparatus, 
although I think these symptoms generally indicate that the 
primary lesion is in the labyrinth. It is no proof that a disease 
of the ear is situated in the tympanum, because the drum-head 
has not a normal appearance. I think this fact has been lost 
sight of, and that occasionally cases of disease of the nerve have 
been put down to the middle ear simply because a drum-head 
was sunken or opaque. How few so-called normal membrana 
tympani are to be found, only he who has searched for them 
among people with good hearing power, can certainly know. A 
disease of the tympanum in childhood may leave its traces upon 
the membrana tympani without sensibly impairing the hearing 
power. The condition of the ossicles and of the lining of the 
tympanum have the most to do with determining the hearing 
power, when the nerve is sound. To them and not to the drum- 
head should we look for information as to the middle ear. Be- 
sides, changes may occur in the drum-head, secondarily to dis- 
ease of the membranous labyrinth and trunk of the acoustic 
nerve. Disease may travel outward as well as inward 



ACOUSTIC NEURITIS AND ATROPHY. 595 



CASES ILLUSTRATIVE OF PRIMARY DISEASE OF THE ACOUSTIC NERVE, 
ACOUSTIC NEURITIS, OR ATROPHY OF THE ACOUSTIC NERVE. 

Case I. — I. P. H , aged fifty-nine, farmer. Sent by Dr. G. W. Holmes, 

April 26, 1880. The patient thinks he has been growing hard of hearing for a 
year. The son (Dr. H.) believes that this period could be extended back to 
three or four years. He has some tinnitus, but this symptom does not seem to 
be a marked one. His ears have never received any treatment. He hears the 
watch E. -£g, L. -^ ; my voice, in a room fifty feet long, twenty-five feet. The 
aerial conduction is said by him to be twice as loud as that through the bones. 
He has large auditory canals. Both membranse tympani are depressed. The 
light spots are fully formed. There are opacities at the margin. Common air 
and vapor of chloroform, used by my attachment to Politzer's bag, redden the 
drum -heads, but the patient does not feel them enter the drum, nor does the 
hearing improve after the ears are inflated. 

The points in favor of a diagnosis of disease of some part of 
the labyrinth or acoustic nerve in this case, to my mind are : 

1. The lessened conduction by bone. 

2. The fact that although his ears have never before been 
inflated, no improvement results from forcing air into the tym- 
pana. 

3. The voice is heard much better relatively than the tick of 
a watch. 

Those who are inclined to make a diagnosis of disease of the 
middle ear from the appearance of the membrana tympani 
alone, will perhaps make one in this case. 

Case II.— Mr. S , aged forty six, sent by Dr. E. Dupuy, October, 20, 1880. 

This patient is a large, well-developed man of great intellectual activity, who is 
engaged in great enterprises in the Western States. He leads a very irregular 
life, eats very rapidly and very much, takes long journeys very often, but he is 
not intemperate in the use of alcohol or tobacco. He began to have attacks of 
vertigo and nausea five years ago, so that he would be obliged to lie down for 
hours. He had to lie on his back ; could not turn on his side or his belly. He 
thinks he observed tinnitus and impairment of hearing after the first attack. 
Ever since his hearing power has been variable. He hears worse in a noise: low 
tones are heard best; music is disagreeable. He has no pain in his ears; the attacks 
of vertigo are growing less frequent. Has a sense of general dizziness. Some- 
times he falls in the street. ■ He has flatulent dyspepsia. He never has had any 
venereal disease. Says he has been prescribed for by " twenty aurists." 

For the watch his H. D. is R. ^, L. ^ ; voice, three feet. The tuning f oik 
"C" is heard on the teeth " slightly ; " not at all on the forehead, nor on any 
jioint of the skull, except on the tip of each mastoid. The aerial conduction is 
much better than the bone on each side. His pharynx is granular. Both mem- 
branse tympani are somewhat depressed; they are not of good color, and the 
light spots are small. The air enters each ear by Folitzer's method, and after 
inflation the H. D. on the left side is ^ § ; before it was ^ . 



596 ACOUSTIC NEURITIS A1SD ATEOPHY. 

This I believe to be a mixed case, that is to say, one of the 
middle ear and of the labyrinth. But I believe the disease of the 
middle ear to be of slight importance, and not to be the cause of 
the great loss of hearing and the head symptoms. In this case 
my diagnosis is based upon : 

1. The suddenness of the symptoms. 

2. The fact that the patient hears worse in a noise. 

3. That he hears low tones best. 

4. That music is disagreeable to him. 

5. And that the aerial is better than the bone conduction. 
The variableness of his hearing power, which, however, is 

never good, as I found by several careful examinations, is due, 
I think, to the catarrh of the tympanic cavities and Eustachian 
tubes, which he undoubtedly has. I do not think the symptoms 
of labyrinthine pressure are secondary to those of the middle 
ear, because he has submitted at various times to anti-catarrhal 
treatment, with no marked benefit. Speculation as to the path- 
ology of the lesion of the acoustic nerve is perhaps useless ; yet 
I cannot but suppose that in this case either an inflammatory or 
a hemorrhagic exudation has occurred. There is no record that 
the patient's urine was examined. I think it was with a nega- 
tive result. A regular life was advised for the patient, but this 
he declined, and I anticipate that I shall one day hear that he 
has succumbed to central disease. 

Case III. — J. J. Mc , postal agent, aged forty. Sent by Dr. Collins, 

March 11, 1881. When a boy suffered from tinnitus. Until one year and a half 
ago heard well. Attention was called to his impairment of hearing by his 
friends. Does not hear as icell on the railway cars as other people. His occupation- 
keeps him on the railway more than half of the time. It is worse when he is 
tired ; appears to be in good health ; never has had venereal disease ; temperate. 
H. D., E. A, L. - 4 %. 

Voice, about one foot from the ear, not well even there. 

The bone conduction is somewhat better than the aerial on both sides ; both 
are feeble. 

Membrana tympani of right side is hypersemic ; there is no light spot. Left 
side Mt. is pale, and there is no light spot ; pharynx normal. 

In this case, there is, I think, disease of the middle and in- 
ternal ears, but I think that of the labyrinth predominates, on 
the following grounds : 

1. Inability to hear better, or even as well as ordinarily, in 
the noise of a railway carriage. 

2. Feeble bone and aerial conduction. 

3. Absence of nasal and pharyngeal symptoms. 

I think acoustic neuritis has supervened upon a chronic non- 
suppurative inflammation of the middle ear ; that he had an 



ACOUSTIC NEURITIS AND ATROPHY. 597 

affection of the middle ear in childhood is shown by the testi- 
mony as to tinnitus, and the appearance of the drum-head. 

Then again, the tuning-fork, although feebly heard through 
the air as well as through the bones, is rather better heard 
through the bones than the air. But that he had serious disease 
of the acoustic nerve is, I think, indicated by the fact that he not 
only did not hear better in the noise of a railway carriage than 
when in an ordinarily quiet place, but that he heard worse than 
people in general. The hypersemic drum-head unattended by 
pain indicates, I think, hyperemia of the whole apparatus, and 
I would classify this also as a mixed case, but one in which the 
nerve was predominantly and chiefly affected. 

Case IV. — J. S , lawyer, aged fifty-eight. Ten years ago the patient ob- 
served that he could not hear distinctly. He suffered also from "catarrh." He 
hears no better in a car or carriage. His sense of taste and smell are defective. 
His throat and nostrils have been treated a great deal, but he grows slowly 
worse. His hearing distance for the watch is ?^f| e - d on each side. He hears con- 
versation very well, in a quiet place, when it is addressed to him. The aerial 
conduction is better than that through the bone on each side. Both drum-heads 
are opaque, and the light spots are small. 

Case Y. — Mrs. L. X , aged fifty-one. Has had much trouble during the 

last year, and has grown very " nervous." She also suffers from tinnitus aurium, 
but she does not consider herself hard of hearing, for she hears conversation 
easily. Is very anxious, fears she will have serious head trouble. Hearing dis- 
tance ^ on the right side, on the left i-|. Aerial and bone conduction are about 
the same on the right side. Aerial louder than bone on the left. The right 
auditory canal is eczematous to a slight degree. The right membrana tympani 
is opaque. The left is also, and there is a small light spot. The pharynx is 
normal. The patient has been treated through the nose and throat without 
benefit. 

It is useless to multiply these cases. They are not rare, 
but they are commonly supposed to be cases of catarrh of the 
middle ear. They are, I believe, actually affections of the acous- 
tic nerve or labyrinth. What their nature is, more exactly than 
this, I cannot say, but I suspect some of them to be cases of 
acoustic neuritis, and that they finally end in atrophic changes. 
I know of no local treatment that is of any use. What may be 
done by the injections of pilocarpine is yet to be shown. Polit- 
zer uses a two per cent, solution of the muriate subcutaneously. 
He injects four drops of this solution at first, and gradually in- 
creases the dose to ten drops daily. If the results are no better 
than those obtained by the hypodermic injection of strychnia 
in atrophy of the optic nerve, not much is to be expected from 
the remedy. Yet the prognosis in this class of cases is not so 



598 PRESBYKOUSIS — ABSOLUTE DEAFNESS. 

bad as in a slowly advancing case of catarrh or of proliferous 
inflammation of the middle ear. The disease generally occurs 
after middle life, and I think many of the patients preserve the 
power to hear conversation addressed specially to them, lectures, 
sermons, and so forth, up to an advanced age. They hear badly 
in a theatre, however, where the dialogue is animated. Persons 
who, after middle life, lose much of their hearing from dis- 
ease of the tympanum and Eustachian tube, soon become un- 
able to hear conversation, and are much more disabled than 
those who suffer from chronic acoustic neuritis or atrophy. It is 
possible that there is a failure of the power of the tensor tym- 
pani and of the stapedius muscle in advancing life, which ren- 
ders it impossible to properly regulate or focus, so to speak, the 
sound image upon the terminal apparatus. In such cases the 
patient's hearing for his range, is as good as that of those with 
active muscles, and young crystalline lenses. There may be in- 
deed a presbykousis as well as a presbyopia, but these cases may 
be distinguished from those I am attempting to describe. 

Treatment. — The treatment of acoustic neuritis, or atrophy 
of the chronic form, should be based upon the general condition 
and habits of the patient. Care and worry, indigestion, the 
menopause in women, will often be found to be at the origin of 
them, and no special treatment can be undertaken until each 
case is studied by itself. But inflation of the ears and active 
treatment by the Eustachian tube, invariably make these people 
worse, and such means are to be strictly avoided. 

POSITIVE SYMPTOMS OF DISEASE OF THE LABYRINTH. 

When absolute deafness exists, we certainly have disease of 
the labyrinth. We may, it is true, have mere impairment of the 
hearing, and yet find disease of the labyrinth ; but if the deaf- 
ness is absolute, or nearly so, we must conclude that the essen- 
tial part of the organ of hearing is invaded. It is a very rare 
thing indeed, that the impairment of hearing from disease of 
the middle ear becomes so profound that words spoken into the 
ear through a tube cannot be distinguished ; but in many of the 
cases of deafness from cerebro-spinal meningitis, from fevers, 
from apoplexy of the labyrinth, from injuries, no words, how- 
ever conducted to the ear, can be made out by the patient, he 
cannot hear his own voice, and total deafness, not merely great 
impairment of hearing, exists. The auditory nerve may have 
some perception of sound in these latter cases ; but these per- 
ceptions can only be compared to the flashes of light seen by 
amaurotic patients. 



THE TUNING-FORK. 599 

This is in accordance or in analogy with what we observe in 
diseases of the eye. When absolute blindness occurs, we know 
that we are dealing with an affection of the central or percep- 
tive apparatus. Opacities of the cornea, cataract, iritis, do not 
destroy the perception of light. This is only done by diseases 
of the retina, optic nerve, or brain. 



SYMPTOMS OF DISEASE OF THE MIDDLE EAR AND LABYRINTH. 

Other symptoms of disease of the internal ear, such as ver- 
tigo, nausea, vomiting, tinnitus aurium, double hearing, are 
also seen in affections of the middle ear, when the nerve-expan- 
sion in the labyrinth is involved by undue pressure. A stagger- 
ing gait, or loss of equilibrium, is also a symptom of disease of 
the internal ear, and especially of the semi-circular canals. But 
even when this symptom occurs, it is not possible to determine 
from it alone, whether the disease of the internal ear is a pri- 
mary or secondary affection. 



THE TUNING-FORK. 

As I have repeatedly said, the tuning-fork is very valuable as 
a means of diagnosis in suspected nerve-deafness. As we have 
seen in the second chapter, the tuning-fork is heard more dis- 
tinctly if the ears be stopped with the finger or the like, while 
the handle is placed upon the forehead or teeth. If a person be 
affected with disease of the internal ear, it is a clinical fact, that 
such a stoppage of the meatus does not usually at all intensify 
the sound of the tuning-fork. Besides, if one acoustic nerve be 
diseased, while the other is sound, or if one be affected much 
more than the other, the tuning-fork is heard more distinctly on 
the sound or better side, just the contrary from what is found in 
disease of the middle ear. 

If a tuning fork (pitched in bass C) be placed on the vertex 
or on the mastoid process, and allowed to vibrate until the notes 
are no longer heard, and its prongs be then brought close to the 
ear, if the ear be normal the tone will be heard again. This is 
called Renne's positive experiment. According to Lucae, in 
those cases of impairment of hearing, where the fork is heard 
again after having ceased to be heard on the vertex or mastoid. 
when placed close to the ear, there is disease of the internal ear. 
When it is not heard again there is disease of the external or 
middle ear. I have had some experience with this test, and I 
believe it to be a good one. But like all the other methods of 



600 THE TUNING-FOEK. 

using the tuning-fork for a differential diagnosis, when em- 
ployed alone it is not sufficient to enable us to speak positively 
as to its diagnostic value. 

At my suggestion, Dr. J. B. Emerson, Assistant Surgeon to 
the Manhattan Eye and Ear Hospital, 1 undertook the examina- 
tion of persons with normal hearing power, by means of the tun- 
ing-fork. The results he obtained are a positive contribution to 
the subject. It is to the tuning-fork that I think we must look 
as yet, for that much-to-be-desired means of making a diagnosis 
between a chronic affection of the middle ear and a similar one 
of the acoustic nerve. Fifty persons with normal hearing were 
carefully chosen from a hundred, said to have normal hearing. 
Two forks were used, one 32J ctm. long, with cylindrical prongs 
and handle, giving a note more than an octave below the middle 
C. C 1 = 261 double vibrations. This tuning-fork is called "A," 
in Dr. Emerson's tests. 

Another fork, about 17 ctm. long, with rectangular prongs 
and conical handle, giving a note one octave above middle C, 
and called " C 2 " = 528 vibrations. 

The average duration of time in seconds during which these 
forks were heard is shown by the following table. The table 
was made up from fifty cases of persons who had no disease of 
the ears. 

"In every case the A fork was loader when heard through 
bone, and the C 2 fork, when heard through air. 

" The average duration in seconds was as follows : 

"A fork- 
Air conduction 31 

Bone conduction 18 

Excess in air conduction 13 

"C 2 fork- 
Air conduction 36 

Bone conduction 16 

Excess in air conduction 20 

"A and C 2 forks- 
Air conduction 34 

Bone conduction 17 

Excess in air conduction 17 

" A and C 2 are both heard longer through aerial than through 
bone conduction. 

"The difference between air and bone conduction is less for 
the A note than for the C 2 note ; A being heard about 1.75 times 
longer through air than through bone; while C 2 was heard 
about 2.25 times longer through air than through bone. 

1 The complete paper will be found in the Archives of Otology, Vol. XII., p. 63. 



THE TUNING-FORK. 601 

"For both A and C 2 , the average duration is twice as long 
through the air as it is through the bone." 

Dr. Emerson also examined fifty persons suffering from dis- 
ease of the middle ear, with the same tuning-fork, and he con- 
cludes as follows : 

1st. Belying on the statements of patients in regard to the 
loudness of tuning-forks, as a test in ear troubles, will lead to 
error unless account is taken of the fork used. As a rule, in 
normal ears high notes are heard louder through aerial con- 
duction, and low notes louder through bone conduction. This 
is true also, to a limited extent, in diseased ears, as verified by 
the thirty-nine cases cited. 

2d. The relative duration of aerial and bone conduction is a 
better test. In normal ears, in all cases the tuning-fork is heard 
longer through air than through bone, the proportion being 
greater for high than low notes ; and for the middle C (C 2 ) it 
should be heard about twice as long through air as through 
bone, the average duration in my cases being for bone seven- 
teen seconds, and for air thirty-four seconds. Any marked de- 
parture from this indicates disease. 

3d. In external- or middle-ear disease this proportion is re- 
duced, and in well-marked cases the average bone conduction 
remaining the same or being increased, the aerial conduction 
will be reduced until it becomes equal to or much less than bone 
conduction. In one hundred ears tested, the average duration 
was for bone seventeen seconds, for air thirteen seconds, or 1.3 
longer through bone than air. This reduction obtained also in 
the thirty-nine cases in which air conduction was louder than 
bone, the average duration in those ears being equal. 

4th. When the bone conduction is longer than aerial conduc- 
tion, and yet much less than the average duration of bone con- 
duction for normal ears, it is an indication not only of middle-ear 
trouble, but that the nervous apparatus is involved. 

5th. If the proportion between bone and air remain the same, 
and the hearing power much lowered, it is probably an indica- 
tion of disease of the internal ear. Air conduction markedly 
exceeding bone conduction, the bone conduction may be entirely 
lost, and yet air conduction continue to a limited extent. 

The two following cases illustrate this : 

Case I.— Mr. , aged forty-five. Chronic alcoholism. H. P., Eight ear 

-A, A tnning-fork heard louder through hone, C a louder through air ; duration 
of A tuning-fork through air, thirty seconds; duration of C 8 forty-five seconds : 
duration of A through bone, twenty seconds, of C" through hone, twenty five sec- 
onds. Left ear -/,-,-, A tuning-fork heard louder through bone, C 8 hoard loader 
through air; duration of A through air, thirty seconds, of G 8 through air, forty 



602 DEAFNESS TO CERTAIN TONES. 

seconds ; duration of A through bone, fifteen seconds, of C 2 through bone, fif- 
teen seconds. 

Case II. — Mr. , aged twenty-three. Meningitis. H. D., Eight ear, - 4 %, 

A heard louder through bone, C 2 through air ; duration of A through air, ten 
seconds, of O 2 through air, twenty-five seconds ; duration of A through bone, 
three seconds, of C 2 through bone, five seconds. Left ear, - 4 a (T , A heard louder 
through bone, C 2 through air ; duration of A through air, ten seconds, of C 2 
through air, twenty-five seconds ; duration of A through bone, five seconds, of 
C 2 , ten seconds. 

It is from experiments such as these, and long experience 
with patients, that I have come to the conclusion that the best 
method we have of diagnosticating or of assisting in the diag- 
nosis of doubtful cases of disease of the internal ear, is the tun- 
ing-fork "C 2 ," generally known as "C" vibrating the second 
one described in Dr. Emerson's tests. If the tuning-fork "C 2 " 
be heard louder and longer through the air when placed near 
the ear, than it is when placed on the mastoid process, ive prob- 
ably have a disease of the nerve, while if it be heard better 
through the bone, we have disease of the middle or external ear. 
For the sake of brevity, we may say, if, in cases of impaired 
hearing, aerial conduction be better and longer than bone conduc- 
tion we have disease of the internal ear. If bone conduction be 
better than aerial, there is disease of the middle or external ear. 

The test with musical tones of various heights is of impor- 
tance in detecting partial defects in hearing tones, but it cannot 
be relied upon as an exclusive test, as some authors are disposed 
to make it. 

In some cases of disease of the middle ear, of one side, the 
aerial conduction disappears entirely, and the conduction through 
the bones is so intensified by the blocking up of the tympanum 
and the rigidity of the ossicles, that when the tuning-fork is 
placed upon any of the bones of the skull, even upon the mastoid 
of the sound side, its vibrations seem to the patient to proceed 
from the diseased ear. 



DEAFNESS TO CERTAIN TONES. 

If Helmholtz be correct in his theories, deafness to certain 
tones must of necessity be due to some affection of the cochlea, 
and this is an affection sometimes seen, as has been known 
since the experiments of Wollaston, who found that some per- 
sons were unable to hear the chirping of a cricket, which is the 
highest tone known. If we accept the theory of Helmholtz, 
that Corti's organ in the labyrinth is a resonance apparatus, and 



DOUBLE HEARING. 603 

that individual fibres of the auditory nerve in the cochlea are 
tuned for certain notes, the pathology of such cases becomes 
clear. It should be remembered, however, that this symptom, 
as well as double hearing, like tinnitus aurium, may be merely 
secondary to an affection of the middle ear, which causes jjress- 
ure upon and hyperemia of the cochlea. 



DOUBLE HEARING. 

One of the first, if not the first, accounts of this phenomenon, 
is by Sir Everard Home, who described it in an article on " The 
Membrana Tympani." ' His case was that of " a music master " 
who perceived a confusion of sounds in his ears after catching 
cold. He discovered that the pitch of one ear was half a note 
lower than that of the other ; and that the perception of a single 
sound did not reach both ears at the same instant, but seemed 
as two distinct sounds following each other in quick succession, 
the last being the lowest and weakest. 

Mr. Home naively remarks that " this complaint distressed 
him for a long time, but he recovered from it without any medi- 
cal aid." This was a case of true double hearing, correspond- 
ing fairly well to double vision. Since then cases have been 
reported by Gruber, 2 Moos, 3 Knapp, 4 S. M. Burnett, 5 myself, 
and others. In Knapp's case the patient heard all tones of the 
middle octave of a piano two tones higher than in the sound 
ear. The ear was affected with suppuration of the tympanum. 
Burnett's case was also that of a professor of music, who ob- 
served that an A tuning-fork, when held before the right ear, 
sounded from f to \ a tone flat. Ten years after he observed 
that the same fork, when held before the same ear, sounded one 
tone higher. His hearing distance was T 1 -g for the watch, and the 
membrana tympani was healthy in appearance. This patient 
seems to have been unable to detect this false hearing of one ear, 
unless he held a tuning-fork before the meatus. It was conse- 
quently rather a curious phenomenon than a source of annoy- 
ance to the subject of it. 

It will be observed that the cases of Home and Knapp are in- 
stances of true double hearing — that is, two distinct sounds wore 
heard simultaneously, one true and the other false. This is dip- 
lakousis, to which the addition of an adjective, binaural is. is 

1 Transactions of the Royal Society, 1800. 

2 Lehrbnch, p. 626. 

3 Klinik der Ohrenkranklieiten, p. 319. 

4 Transactions of the American Otologioal Society. 1871. 

6 Archives of Ophthalmology and Otology, vol. v., p. 507. 



604 CASES OF DOUBLE HEARING. 

only confusing. Burnett's case is one of false hearing*. When the 
true notes are heard and then a false one, or when the last notes 
are repeated or echoed, we should speak of echo-hearing. 

Double hearing and echo-hearing exist very often as symptoms 
of pressure upon the labyrinth from disease of the middle ear, 
or possibly from independent disease of the labyrinth, but such 
symptoms are generally complained of only by people of good 
musical education, and affect only the higher notes of the scale. 

Sometimes the same condition prevails in both ears, and all 
notes are heard false. This should also be called echo-hearing. 

In 1877 I saw and treated, for a short time, a patient who 
presented the following curious phenomena of hearing : With 
the right ear he can hear the high notes of a piano better than 
the low ones ; in walking on the sea-shore he hears the crickets 
in the grass, but not the roar of the waves ; he can hear the 
chirping of insects and the movements of their bodies easily ;' the 
tick of a watch is heard normally, J|, and yet he cannot hear 
the tones of the human voice at all well. With the left ear, 
whose hearing distance for the watch is but ^, the power of 
hearing conversation is so good that the patient, a young man 
of seventeen, carries on his studies at college with no particular 
difficulty. 

Acute Suppuration of Right Middle Ear — Hypercemia of Labyrinth of Same 

Side — True Double Hearing. — P. A. S , aged twenty-five; pianist. October 

18, 1875. Seen with Dr. E. G. Loring. This r>atient is suffering from an acute in- 
flammation of the right middle ear, presenting the usual symptoms, but he also 
presents the phenomenon of so-called double hearing. In striking any musical 
instrument — piano, organ, or violin — he hears the half -note above in addition to 
the one struck. He hears both notes together. The false note gradually dies out, 
leaving finally only the sound of the note struck. He observes this when both 
ears are open, and when the sound one is closed. He has never tried closing 
the diseased ear. This phenomenon lasted about three weeks. It disappeared 
gradually, the false note being nearer and nearer to the true one, until it finally 
blended with it. 

At my request this patient sent me an account of his case, 
which is here reproduced. 

About the year 1851 (when only one year old), I was taken sick, and I ailed 
for about twelve or fourteen months, but I recovered. As long as I can re- 
member back, I complained of my hearing ; the left ear was all right, but it 
seemed to me that I could have done just as well without the right ; hearing 
with one and hearing with both was all the same thing. 

My parents took me to a physician, who cleaned and syringed it for me, but 
nothing else was done to it. When I was about six years (that is, after this 
physician had cleaned it), it began to discharge a little. It really did stop run- 
ning, but the hearing never improved. I studied music, and could always boast 



CASES OF DOUBLE HEARING-. 605 

of as true an ear as any musician could wish for. In the autumn of 1874 I went 
to Germany to improve myself further in my profession, and one morning, sit- 
ting in a Leipzig Gewandhaus-Concert (this was in January), I felt a tickling in 
the defected ear, and to my surprise it had discharged again. I went at once 

to Dr. M , who told me, "the drum of the ear was almost gone, and it had 

been an old complaint, but the running he could stop easily." He gave me 
some ear-drops, which had no effect on it at all. Then I had no pain. In July 
I returned to America. In August (the month after) I experienced the first 
pains ; the inside, the whole frame and cheek-bone felt as if it would split. That 
time I came under the treatment of Dr. Loring, who then told me, "the drum 
was entirely gone." He stopped the pain, and the running also diminished, and 
I had good hopes of its being well soon. I kept on syringing with warm water 
and putting in alum, soda, salt, nitrate of silver, etc. , as the Doctor saw fit to 
use. One day in December, 1875, the same old pain (which had kept me awake 
many a night) came back again, and to my astonishment found that my hearing 
was affected in the most alarming manner. Any sound that struck the ear felt 
as if I had got a box on the ear, but what most frightened me was that I heard 
incorrectly. For instance, when I struck C on the piano, I would hear this very 
G ; but in addition I heard the C sharp, which is just half a note above. Now 
imagine my confusion ; by striking the common chord of C (C, E, G), I not only 
heard this, but at the same time G% EJJ, GjJ, being the common chord of CjJ. 
I feared very much I would have to give up my profession and take hold of 
some other occupation, which, I believe, would have been enough to drive me 
crazy. 

At first these two notes (or chords) would sound about equally loud and 
keep sounding wrong until both died away, but after a week or so this wrong 
note C^ would sound like a perfect C£ only at the instant of the key of C be- 
ing struck, but gradually as the sound diminished and the vibrations became 
fewer, this CJJ would get lower until, when the note became quite faint, I would 
at last hear nothing but the true C. 

Playing on an organ this would not be the case, as the sound cannot be 
diminished in the same way as on the piano ; there I would hear the wrong 
note, CJJ, with the right one, C, as long as the sound could be heard. 

On the violin it was worse yet (from the reason, I suppose, of its being nearer 
the head, and the notes being more acute). I could not for the space of four 
weeks play the violin at all, as I knew not when I played right or wrong, for on 
that instrument the wrong note CjJ predominated the one I should only have 
heard (C) by far. The C indeed sounded very faint. If anybody else played 
the violin, the wrong notes would not predominate quite so much. 

With my own voice it was worse yet. If I played on the piano I could toll 
what notes I ought to have heard, but in singing I had no idea how near I sang 
the right note. So everything sounded double and confused. 

The first time I became aware of this bad state was at an evening service at 
St. Luke's Hospital, where I played the organ. After service I told some one 
that the people had sung most awfully out of tune ami something must also be 
wrong with the organ, when I was answered that the music had never sounded 
better. So playing on my piano, I found that my own hearing was the sole 
cause of these discords. I remained in this state for about two weeks. Then 



606 ECHO HEARING. 

instead of hearing a note with the additional half a tone higher (0 and CjJ), I 
heard C and a note between C and C£ (this tone cannot be produced on keyed 
instruments, only on strings) ; after a few days more the wrong note got to be 
nearer the right one, yet (perhaps £ above, and by and by rg above) still I heard 
both instantaneously. The harder I struck a key or note, the louder would the 
additional wrong one sound, but the better the ear got, the purer and clearer 
would my hearing be. At the end of about five weeks this haunting false note 
was quite gone, and ever after that I heard only the note I struck and nothing 
else, and now I attend to my profession, as well and cheerful as I can wish for. 

Deafness from Chronic Suppuration, Left Ear ; Impacted Wax, Right Ear — 

Echo Hearing with One Ear. — Miss L , aged twenty. Had a discharge from 

left ear a long time ago, and has been deaf on that side since. Had a great 
deal of earache when small. Noticed impaired hearing in right ear about three 
weeks ago. Slight tinnitus at times, but no pain or discharge. No cause 
assigned. Since right ear has become deaf, she has been annoyed by " a dis- 
agreeable vibration like an echo " in her right ear, after singing a high note or 
hearing another do so. Has not noticed it in instrumental music. Does not 
sing herself higher than F or G. 

H. D.— E., if, L., A. 

Hears a whisper twenty feet with ease. Piano-test gives a negative result. 
Pharynx looks well. Has some impacted wax in both auditory canals. Drum- 
heads are opaque. After removing wax and inflating ears, H. D. became — E., 
\% L., 4 V The echo disappeared on the same day, and two months after had not 
returned. 

It is hardly necessary to more than allude to the symptom of 
tinnitus aurium in primary disease of the labyrinth. It scarcely 
differs from the sounds heard by those who suffer from chronic 
non-suppurative inflammation, although in many cases of total 
deafness no tinnitus exists, and, so far as my observation ex- 
tends, tinnitus aurium is more frequent and disturbing in chronic 
disease of the middle ear, than in chronic affections of the laby- 
rinth. 

PAIN AND SENSITIVENESS TO SOUNDS. 

Pain is a marked symptom of acute inflammation of the mem- 
branous labyrinth. All affections of the acoustic nerve are, 
however, generally accompanied by extreme sensitiveness of 
the ear to loud, jarring, discordant, or even ordinary sounds. It 
is then necessary to keep the patient in a very quiet place. I 
have several times been compelled to order the patient away 
from the city to the quiet of the country. In all cases of this 
kind the auditory canal should be protected by plugs of cotton. 
Nausea, vomiting, and convulsions, as well as opisthotonos and 
delirium, may be symptoms of labyrinth disease, as well as of 
cerebro-spinal meningitis and of acute catarrh of the middle ear. ' 



PRIMARY INFLAMMATION OF LABYRINTH. 607 

Voltolini is quite positive that there is a primary affection of 
the labyrinth that is sometimes mistaken for cerebro-spinal men- 
ingitis, and he has written several papers, 1 illustrated by cases, 
to sustain his position. Although his ideas have been rejected 
by some other writers, I do not think the question can be at all 
considered as a settled one. After a careful consideration of the 
history of very many cases of supposed cerebro-spinal meningitis 
occurring in young children, there is at least a strong suspicion 
in my mind that Voltolini is correct in this view, and that an 
affection of the labyrinth may occur in young children, and be 
erroneously supposed to be cerebro-spinal meningitis. I have 
had very few opportunities of studying cases of cerebro-spinal 
meningitis, although I have seen a large number of deaf persons 
in whom the loss of hearing was said, upon good professional 
authority, to have occurred during the course of this disease. It 
is very much to be desired, for the clearing up of some points in 
the nature of this disease and its relations to the acoustic nerve 
and internal ear, that those who are accustomed to examine and 
treat cases of aural disease should have opportunities of seeing 
cases of cerebro-spinal meningitis in their acute stages. The 
bonds between specialism and general practice should be very 
close, if real advance in this or in other directions is to be 
made. 

The symptoms of that form of inflammation of the membran- 
ous labyrinth that has been mistaken for cerebro-spinal menin- 
gitis, should be carefully considered in order that the practitioner 
may be able to clear up the doubts which have been thrown upon 
the existence of this disease. Gruber, 2 and Schwartze unite with 
me in believing that such a disease may occur. If we find a 
child suddenly taken with severe vomiting, which is followed by 
stupor or delirium, without paralysis, and with but slight opis- 
thotonos, such as children have with acute otitis media, and 
if we see this child recover in a few days, except that it is 
absolutely deaf, and walks with a staggering gait, I think it is 
more reasonable to think of an affection of the ear as the 
cause of these symptoms, than of a disease of the brain and 
spinal cord. 

Having seen many cases in which such a history was clearly 
given, I must believe in a primary acute inflammation of the 
labyrinth, and I trust the attention of physicians will be directed 
to the differential diagnosis between this affection and cerebro- 
spinal meningitis. 

1 Monatsschrift fur Ohrenheilkunde, Bd. I. and VI. 
s Lehrlmcli, p. 552. 



608 SYPHILITIC COCHLITIS. 



THE DIAGNOSIS OF DISEASES OF THE INTERNAL EAR BY THE MEANS OF 

ELECTRICITY. 

In the former editions of this work considerable space was 
given to this subject, but I have become convinced that the con- 
clusions of those who believe they were able to diagnosticate 
disease of the labyrinth by means of the galvanic current, are 
fallacious. I do not think it has yet been demonstrated that we 
determine the situation or character of a lesion in the ear, by 
means of electricity, and I do not advise the student of aural 
disease to concern himself with the various theories upon the 
subject. 

I will now discuss some of the well known causes of primary 
disease of the labyrinth. 

DISEASE OF THE COCHLEA (COCHLITIS) FROM SYPHILIS. 

Syphilitic affections of the middle ear are perhaps more com- 
mon than those of the labyrinth. For example, in the course of 
the earlier symptoms, among which is pharyngitis, and so forth, 
we often have tubal and tympanic catarrh, which is not to be dis- 
tinguished from an aural catarrh arising in the course of an- 
other disease, so far as the ear is concerned. There may be also 
in the course of the later periods of the disease, a syphilitic exu- 
dation into the tympanum, and about the ossicles. There is, 
however, a disease of the labyrinth and acoustic nerve occurring 
in syphilis. This disease has some characteristics of its own. 
It is analogous to certain forms of what are known as brain or 
nerve syphilis, such for example as lesions of the ocular motor 
nerves, and the medulla. I have given it the name of syphilitic 
cochlitis, simply because it seems plain to me that it is as well 
defined, as being chiefly a disease of the cochlea, as are certain 
affections of the semi-circular canals of the optic nerve and 
retina. The cases of diseases of the ear in inherited syphilis, 
which I have had the opportunity of studying, seem to me to be 
chiefly diseases of the peripheric and not of the central part of 
the organ of hearing. Just as we have disease of the cornea 
and iris as the more frequent lesions of the eye in congenital 
syphilis, so do we have tubal and tympanic catarrh, originat- 
ing from the snufnes in infantile and congenital syphilis. 

Mr. Hutchinson ! is of the opinion that all the cases of aural 
disease occurring in the course of inherited syphilis, which he 



1 A Clinical Memoir on Certain Diseases of the Eye and Ear, consequent on Inher- 
ited Syphilis, p. 182. London, 1863. 



SYPHILITIC DISEASE OF LABYRINTH. 609 

inspected, are "due either to disease of the nerve itself or to 
some change in non-accessible parts of the auditory apparatus." 
I think that Mr. Hutchinson has not attached enough import- 
ance to the throat symptoms in his cases, and that thus he has 
been led to give diseases of the labyrinth an undue preponder- 
ance in aural affections resulting from syphilis. The fact that 
the Eustachian tubes are "pervious" goes but a very little way 
to sustain the theory of labyrinth disease, and Mr. Hutchinson 
admits that his cases showed changes in the membrana tympanf, 
but not "adequate" ones. After or during the course of the 
snuffles of syphilitic children, we are very sure to have catarrh 
of the middle ear. The following case illustrates the difficulty 
of making a positive differential diagnosis between middle ear 
and labyrinth disease in the existence of a syphilitic diathesis : 

Acute Pain in Right Side of Head along the Course of the Fifth Nerve , followed 
by Impairment of Hearing and Tinnitus Aurium — Gradual Loss of Hearing more 
marked on the Bight Side — Primary Syphilis One Year since followed by Mucous 

Patches and Erythema. — Mr. X , aged twenty -nine, May 26, 1873, was sent to 

me for advice, by Dr. E. Hubbard, of Bridgeport, Conn. The following history 
was given by Dr. Hubbard and the patient : One year ago he had a chancre in 
the urethra, followed by mucous patches and erythema. He was treated by the 
use of mercury and iodide of potassium, and recovered very rapidly from those 
symptoms. About five weeks ago the patient was seized with a severe pain in 
the track of the fifth nerve, with tinnitus aurium. The tinnitus was compared 
by the patient to the peep of a chicken, although this variety of noise was not 
the only one observed. There was no pain in the ear itself. The general health 
is excellent. The hearing had gradually diminished in the right ear since the 
pain and tinnitus occurred. The pain subsided in a short time ; the tinnitus 
still continues. The hearing distance is — E., ?^ s g ed ; L., l|. The tuning-fork is 
heard more distinctly in the better ear. When the right ear is closed by the 
finger, however, the tuning-fork is heard better in that ear. The membranaj 
tympani of both sides are sunken, that of the left more so. The light spot is 
nearly obliterated on the right side. There is a small one on the left. Inflation 
of the ears by Politzer's method improves the hearing a very little on each side. 
The pharynx is secreting excessively. 

I suppose this to be a case of sub-acute catarrh of the middle 
ear, with a secondary affection of the labyrinth. The tuni no- 
fork indicates that there is labyrinth disease, and yet the test is 
not positive, because, when the right ear was closed, the sound 
of the fork was intensified on the side of the closed oar. The 
appearances of the drum-head, and of the pharynx, as well as 
the results from the employment of Politzer's method, are, how- 
ever, positive proofs that some catarrh of the middle ear exists. 
The patient is under treatment, both constitutional and local. 

Mr. Hutchinson speaks only of hereditary syphilis in his book. 
30 



610 SYPHILITIC COCHLITIS. 

but there is the same tendency to catarrh of the pharynx and 
Eustachian tubes in inherited syphilis as in any other form. 

There are cases, however, of disease of the ear occurring as a 
result of syphilis, when all the marked symptoms are derived 
from the labyrinth. If diagnosticated at all early in their course, 
they are susceptible of relief and cure by the free use of mercury 
and iodide of potassium. My recent experience has been in such 
gratifying contrast to that which I had had when the first edi- 
tion of this book was published, that I am very glad to report it 
for the purpose of illustrating what has just been said. In the 
cases now about to be quoted, I think we are perhaps justified 
in going a little farther in our classification than merely to state 
that there is disease of the labyrinth. We may, perhaps, diag- 
nosticate disease of the cochlea, or at least say that the affection 
of the cochlea is predominant in certain cases, just as we may 
speak of disease of the semi-circular canals, when vertigo and 
staggering are the predominant symptoms. Syphilitic cochlitis 
may perhaps be a proper name for this class of cases. 

Before quoting the cases in question, I will tabulate certain 
conclusions which afford a guide to the determination of the 
situation and character of the lesion where there is a doubt. 

1. Disease of the cochlea, as of the other parts of the laby- 
rinth, usually, although not always, manifests itself suddenly. 
The patient can definitely fix upon a time when he became deaf, 
and when he began to have tinnitus aurium. This is true even 
when one side only is affected. The one-sided deafness would 
not be so quickly recognized were it not usually accompanied by 
tinnitus, vertigo, and often by unsteadiness of gait. Sudden 
loss of hearing and the sudden occurrence of tinnitus, vertigo, 
and staggering, are not, however, entirely peculiar to labyrinth 
disease, since it is well known that we sometimes, although 
rarely, have the same symptoms in cases of inspissated cerumen 
and catarrh of the middle ear. They are therefore only of path- 
ognomonic value in connection with the objective examination 
and tests. 

2. The tuning-fork C 2 is heard more distinctly through the 
air than through the bones. 

3. The examination of the membrana tympani and the em- 
ployment of the methods for inflating the middle ear, will usu- 
ally give us reasonable conclusions as to the situation of a given 
disease of the ear, so that at the least we may exclude collec- 
tions of fluid in the tympanic cavity in making a differential 
diagnosis between disease of the middle ear and of the laby- 
rinth. 

4. The piano, or any very similar musical instrument, will 



SYPHILIS OF THE LABYRINTH. 611 

aid us in determining whether or not disease of the cochlea ex- 
ists. The examination of cases that were unquestionably affec- 
tions of the labyrinth shows that the power of appreciating low 
tones is the last to suffer, and the first to recover in most cases 
of disease of this part of the ear, so that these will be heard 
when the high ones are either not heard at all, or are heard 
''false" or doubled. From our present knowledge of the phys- 
iology of hearing, when these symptoms are present, we must 
conclude that the cochlea is the seat of disease, even if it be 
secondarily affected. 

5. The diagnosis of syphilis of the labyrinth depends in a 
great measure upon the same kind of evidence as that from 
which we conclude that a case of optic neuritis or choroiditis is 
syphilitic ; that is to say, the history and the presence of other 
symptoms such as an eruption, mucous patches, etc. It should 
not be forgotten, however, that the occurrence of labyrinth dis- 
ease, in a person who has probably had the initial lesion of 
syphilis, even if no other symptoms are present, is a very sus- 
picious circumstance, which should lead to a careful weighing 
of the indications for and against a mercurial treatment. 

I prefer to say disease of the cochlea, instead of disease of 
the labyrinth, when the prominent symptoms, as in the cases 
now reported, are great impairment of hearing, the inability to 
hear certain tones, and the production of false ones. These are 
evidences, I think, of cochlear disease, whatever else we may 
have. Tinnitus is a symptom common to many forms of aural 
affections, while vertigo and unsteadiness of gait are chiefly to 
be referred to undue pressure from the base of the stapes upon 
the semi-circular canals, and not to disease of the cochlea. I 
think too much stress has been laid upon increased pressure 
upon this latter-named part of the ear, to the neglect of disease 
having its origin in the tone-perceiving apparatus — the cochlea. 
"Meniere's disease "has always seemed tome an unfortunate 
name, since it has been indiscriminately applied. It ought not 
to be used unless it refers to a case such as that in which a hem- 
orrhage into the semi-circular canals was found. Of late, cases 
in which the cochlear symptoms are, at least, the predominant 
ones, are sometimes styled cases of "Meniere's disease." when 
they have very little in common with cases of hemorrhage. It 
is interesting to notice that we are always assisted in a diag- 
nosis of supposed cochlear disease, if the patient have a musical 
education. I believe all the cases of double hearing thai have 
been reported occurred in persons enjoying a musical training. 
Certainly other patients have had the same symptoms, hut they 
have been unable to appreciate them. The power of hearing 



612 SYPHILIS OF THE LABYEIXTH. 

certain tones can, however, be accurately tested in all patients 
except young children. 

The pathological investigations of syphilis of the internal ear 
have not been numerous, but we are not entirely without them. 
Moos * reported a case of secondary syphilis, in which deafness, 
annoying tinnitus aurium, and osteocopic pains in the skull were 
complained of. The hearing was rapidly destroyed. Death. 
At the autopsy the right external and middle ear were found 
intact, sclerosis of the petrous portion of the temporal bone, 
periostitis in the vestibule and small-celled infiltration of the 
membranous labyrinth, anchylosis of the stapes to the fenestra 
ovalis. Trunk of the acusticus unchanged. 

Gruber has also reported a similar case." Gruber's patient 
died of typhus fever. A post-mortem examination of the ear 
showed vascular injection of a high degree in the soft tissues of 
the labyrinth as well as thickness of these parts, in connection 
with marked hypersemia of the mucous membrane of the tym- 
panum. The patient, who was syphilitic, and who had been 
very slightly hard of hearing at times from catarrh of the 
tympanum, became suddenly absolutely deaf, with occasional 
attacks of vertigo when he first became deaf. The vertigo 
disappeared, but the deafness remained. 

I have never believed that the affection which I have de- 
nominated cochlitis involved the cochlea solely, but that it 
affected that part of the ear predominantly, just as a patient 
may have severe hyperemia, and even inflammation of the 
external auditory canal, quite secondary to the main trouble in 
the middle ear. 

It would be very convenient indeed, if we could separate 
diseased parts from each other by a line as distinct as that 
in facial erysipelas, or, to use a geographical comparison, as 
marked as the separation of Mexico from the United States by 
the Rio Grande ; but to give the exact line of demarcation in 
disease is very often impossible. It must be named from the 
predominance of the symptom in certain parts or organs. 



CASES. 

Case I. — Sudden Loss of Hearing and Tinnitus — Primary Syphilis — Alopecia- 
Eruption — Anti-syphilitic Treatment — Cure. — W. M , aged thirty-seven. The 

patient states that five weeks ago, on one particular day, he observed that his 
hearing was impaired and that he had a noise in his ears. From that time to 
this he has grown worse. He also states that his hearing is worse at night. 

1 Medical Eecord, from Centralblatt fur Chirurgie, August 19, 1877, from Yir- 
chow's Archives. s Lehrbuch, p. 617. 



CASES OF SYPHILITIC COCHLITIS. 613 

About six months ago he had a chancre ; three months later he had alopecia ; 
and there is now a copper-colored papular eruption upon his wrists and arms. 

Hearing distance: K., -fy; L., ^. 

The tuning-fork is heard better in the left ear. The pharynx is granular and 
in a hypersecretive condition. The drum-heads both show small light spots. 
The usual treatment for catarrh of the middle ears has been employed since the 
attack of tinnitus and the loss of hearing, but without success. 

The patient was immediately placed upon anti-syphilitic treatment, which he 
carried out with but moderate faithfulness, but he began at once to improve. 
Two months after his tinnitus was relieved, and the hearing distance was: E., 
Preswd. l ^ _6_ After this he went under the care of Dr. Sturgis for other symp- 
toms of syphilis, and he informed me that he heard very well. 

Case II. — Syphilitic Ulcer on Os Uteri — Loss of Hearing — Alopecia- Eruption — 

Recovery. — Mrs. X , aged thirty-one. April 8, 1875. Seven weeks ago this 

patient, who was brought to me by her husband, a physician, began to observe 
an impairment of hearing, accompanied by a dull pain and by tinnitus. 

Hearing distance : E., \% ; L., -£%. 

The husband, and the note of a physician who had supervised the treatment 
of the patient, state that she had not been well since the birth of her child in 
August last, when an abrasion (syphilitic?) was found on the os uteri. This, the 
husband says, was probably produced by infection from his own finger, upon 
which was the initial lesion of syphilis, contracted in attending a case of labor in 
a syphilitic patient. 

The symptoms from which Mrs. X suffered before the loss of hearing 

were neuralgic pains about the eyes, hyperemia of the optic disks, papular erup- 
tion on the chest, and alopecia. There are now traces of the eruption, and the 
patient has a poor appetite, pains in her legs, and some neuralgia about the 
eyes. The treatment was anti-syphilitic in the beginning, but has not been very 
thoroughly carried out of late. The pharynx is granular, and the left dram has 
no light spot. The usual treatment for catarrh of the middle ears has been pur- 
sued to some extent, but with no benefit, for the aural symptoms are increasing. 

A thorough anti-syphilitic treatment was undertaken, and, according to a 
note from the husband and a verbal communication from the physician who first 
observed the case, the patient progressed steadily to recovery under this manage- 
ment. No local treatment was used after the case was seen by me. I hardly 
think general treatment would have been sufficient had the tympanic disease been 
predominant. 

Case III. — Venereal Sore — Loss of Hearing — Vertigo — Double Hearing — Re- 
covery. — Mr. U , aged thirty-three. August 30, 1876. The patient states 

that toward the end of last June he observed dulness of hearing and tinnitus in 
both ears. Soon after he discovered that he was totally deaf as to the left oar. 
and the right ear has been gradually growing worse. 

On August 1st he began to have attacks of vertigo and staggering, and has 
had several since. He had a venereal sore on his penis about February 15th, 
and says he had mucous patches in his mouth and throat about the middle of 
March. 

Hearing distance : E., A; L., ,"„. 

He hears words when spoken distinctly into the right ear. The drum-heads 



614 SYPHILITIC COCHLITIS — CASES. 

are both dull in color and have no light spots. The air enters both tympanic 
cavities freely upon the employment of Politzer's method, and reddens the drum- 
heads, but causes no improvement in hearing. 

A diagnosis of syphilitic disease of the labyrinth on both sides was made by 
my associate, Dr. E. T.' Ely, who saw him first ; and after the patient had seen 
Dr. E. L. Keyes in consultation, he was put upon a course of inunction with the 
oleate of mercury, mercurial baths, and iodide of potassium internally, in steadily 
increasing doses. 

On September 9th he was already better. He could hear the voice much 
better ; the attacks of vertigo continued, but there was no more staggering. 

A more complete examination showed some peculiar symptoms which throw 
some light upon disease of the cochlea, and which are therefore now detailed. 
The noises of the street jar the patient's head very unpleasantly. He cannot 
distinguish sibilants — s sounds like/, etc. The notes of the piano become dis- 
cordant at fifth C. They do not sound double, but false. In the higher notes 
the seventh note sounds more like the octave than the octave itself. 

September 12th. — There is a little more improvement in the hearing. He 
hears notes truly about an octave higher than on the 9th. When an upper note 
is struck he also hears with this the half note above. He still complains of the 
unpleasant effect of the noisy streets. The drugs have been steadily continued, 
and with no unpleasant effects. He is allowed to leave New York and go to the 
sea-side. 

September 19th. — Patient now hears conversation with the right ear at ten 
feet. The left ear seems to have no power whatever. The dose of potash has 
now reached seventy-five grains three times a day. 

October 5th. — Hears the voice at twenty feet with ease. All but the last two 
notes of the piano are heard correctly. In words / still sounds like .s. Is taking 
one hundred and twenty grains potash at a dose three times a day. The patient 
fully recovered his hearing power for ordinary conversation, and resumed his 
profession. The recovery was confined to the right ear. 

It is possible that we have not paid enough attention to the 
protection of inflamed or hyperaemic ears. Boiler-makers may 
protect their ears from the destructive hyperemia caused by the 
concussions to which their work exposes them, by plugging the 
meatus ; and telegraph-operators may suffer from an impair- 
ment of hearing induced by exposure to the continuous clicking 
of a telegraph instrument. In the case just reported, the patient 
experienced great relief from the change of residence from near 
the noisy pavements of New York to the quiet of the sea-side ; 
and I believe where noise produces such a degree of irritation as 
was complained of in this case, we should carefully select a resi- 
dence for the patient with a view to keeping him out of noise. 
In ophthalmic therapeutics a great deal of care is often necessary 
to protect the eyes from the light ; and in acute aural disease, 
and perhaps in some forms of chronic affections, the same care 
should be exercised lest the ears be exposed to loud or continu- 
ous sounds. 



SYPHILITIC COCHLITIS — CASES. 615 

Case IV. is one that I saw at the Manhattan Eye and Ear Hospital, through 
Dr. E. T. Ely, who had charge of the patient at the Eastern Dispensary, and 

who diagnosticated disease of the labyrinth. Mr. L , aged twenty-two. 

September 7, 1876. Complains that two days ago he was suddenly attacked by 
complete deafness in the left ear, accompanied by noises like ' ' the blowing off 
of steam." These symptoms have continued, and he has also had slight vertigo 
and feeling of unsteadiness — most troublesome when he turns his face upward. 
He had a venereal sore on his penis two years ago, and subsequently sore mouth, 
falling of his hair, and iritis. Was treated for syphilis by reputable physicians. 

Hearing distance : E., IS ; L., - 4 %. Tuning-fork heard only on the right side. 
Drum-heads somewhat sunken, with dull color and dull light spot. Air enters 
middle ears readily through Eustachian tubes, but it does not improve the 
hearing. 

September 20th. — Patient has been treated for catarrh of the middle ears, 
without any benefit. Anti-syphilitic treatment was advised at his first visit, but 
he has refused it thus far. 

The diagnosis in this case has not been subjected to the cru- 
cial test of treatment. Its syphilitic character cannot therefore 
be so strongly emphasized. Yet when a history of general syphi- 
lis is so distinct and a labyrinth affection occurs, I think we may 
safely conclude that the latter is at least modified by the venereal 
poison, if not actually caused by it. 

Case V. — Syphilis — Sudden Deafness and Tinnitus — Symptoms of Disease of 

Cochlea — Benefit from Treatment. — Mr. S , aged twenty-eight. First seen 

March 24, 1877, with the following history : About one month ago he noticed 
deafness and tinnitus in the right ear, and, a few days later, in the left. Is not 
sure but that both sides were affected at the same time. Trouble advanced 
rapidly, and in three weeks he was so deaf that he " couldn't hear anything but 
loud noises." Never had any pain or discharge. Tinnitus at first was "like 
somebody tapping on a tumbler;" now it resembles "the wind blowing." Had 
some dizziness and nausea when first attacked. Never vomited. Never has 
noticed any unsteadiness of gait. Has no vertigo now, except when he runs or 
takes a very long stride in walking. Hearing is worse in a noisy place. Thinks 
he hears low notes better than high ones. 

Had a chancre eighteen months ago. Gives no history of any secondary 
symptoms, except of "sores in his mouth." Has taken mercury and iodide of 
potash since a week after his aural trouble began, but without benefit. 

Thinks he took cold a few days before his deafness began, as he had ' v a 
stiffness " of his neck and shoulders. 

H. D. : R., 4^-; L., ±%. Loud voice one foot behind back. Hears words, 
through speaking-tube, in each ear. Hears all notes of piano, but does not 
appreciate difference between low and high ones correctly. 

Tuning-fork heard better on right side. Pharynx looks well. Has ulcera- 
tions on edges of tongue ; Eustachian tubes pervious; no effect from inflation. 
Right drum-head pinkish, good light spot ; left drum-head looks well. 

Diagnosis. — Syphilitic inflammation of cochlea. 

Was seen by Dr. Sturgis in consultation, who found "an undoubted history 
of syphilis," with objective evidences of the disease still apparent. 



616 SYPHILITIC COCHLITIS — CASES. 

Patient was ordered to take a mercurial vapor-bath daily ; daily mercurial 
inunction ; iodide of potash, beginning with 60 grains a day, and gradually in- 
creasing. 

April 6th.— E., -/ s - ; L., &-; voice, 2 feet. 

April 13th.— E., -h; L., &; voice, 2 feet E. E. ; 6" L. E. 

April 21st.— E., & 5 L-, & 5 voice, 4| feet E. E. ; 1* feet L. E. Taking 339 
grains iodide potash daily, with mercurial inunction each night. 

May 25th.— E., -& ; L., - 4 Q S - ; voice, E., 8 feet ; L., 4 feet. Taking 118 grains 
iodide of potash with 20 drops tincture iodine, three times daily. Inunction as 
usual. 

June 4th.— E., ± S E ; L., 4 -| ; voice, E., 4 feet; L., 3 feet. With face toward 
speaker, hears loud conversation 10 feet. Has always shown great difference 
in hearing power for different letters. Hears now w and c best. 

June 25th.— E., 3 9 -g ; L., ■£$ ; voice, 6 feet right side ; 4 feet left side. With 
back to speaker, hears loud conversation at 2 feet. Some sentences at 12 feet 
and more. Facing speaker, hears ordinary conversation easily at 4 feet, and 
some sentences at 20 feet. Has great difficulty with sounds of m, n, b. and p. 
Says he heard the crickets in the grass at the sea-shore but not the sound of 
the waves yesterday. Noises of street disturb him. 

June 29th. — Left the city, with orders to continue treatment. 

July 20th. — Writes that he has gained six pounds since June 29th. 

August 12th. — Writes that he "hears everything quite naturally, except 
music." Sound of running water in ears continues. Gaining flesh and feeling 
remarkably well. Thinks his hearing is still improving a little. 

The record of this case ends here for the present. The patient's highest 
daily dose of potash was 369 grains. The remedies agreed well with him, and 
only had to be interrupted a few times, for two or three days, on account of 
causing disturbance of the stomach. Inflation of the middle ears never pro- 
duced any apparent effect. 

Case VI. — Syphilis — Sudden Tinnitus — Recovery. — Mr. P , aged forty-five. 

July 2, 1877. In July, 1876, noticed a ringing sound in his left ear upon arising 
in the morning. A few days later noticed the same sound in his right ear. The 
tinnitus has remained ever since, and has increased in intensity. In October he 
noticed that his hearing was impaired. The deafness has been increasing until 
three weeks ago, since which time it has appeared to remain the same. Has been 
treated for aural catarrh by two competent aurists (by one for a period of six 
weeks), without any benefit. Has been treated by electricity also, without bene- 
fit. Never had any internal medication. Has occasional dizziness. Health good 
in all other respects. 

Had a chancre in July, 1876, before tinnitus was noticed. Sore appeared 
fourteen days after intercourse, healed slowly, and was accompanied by bala- 
nitis. Never has been aware of any secondary affection of anv kind. 

H. D.: E., -h; L., A- 

Loud voice, six feet at right side of head and twelve feet at left side. Tun- 
ing-fork heard alike both sides, as nearly as he can judge. All the notes of a 
piano "sound alike "to him. Band music sounds very discordant. General 
appearance of both drum-heads is healthy. Pharynx normal. Tubes open. No 
effect from inflation. 

Diagnosis. — Disease of cochlea, both sides, of syphilitic origin? 



SYPHILITIC COCHLITIS— CASES. 617 

Advised a half-drachm of twenty per cent, solution oleate mercury rubbed 
into skin daily, and iodide of potash in increasing doses, beginning with 5 grains 
three times a day. 

August 14, 1877. — H. D., j P g both sides; heard conversation thirty feet be- 
hind back easily. R. E., notes of piano between sixth c and seventh e are not 
heard. Four uppermost notes heard naturally. L. E., notes sound natural up 
to sixth g ; from there to seventh e they sound ' ' all alike, and have no music in 
them ; " above e they are natural again. Hears band music well now ; before it 
was very discordant to him. Violin music is still discordant to him. His own 
voice sounds more natural to him. Is sure himself that he hears everything 
much better. 

This patient left town at this time, expecting to return, but did not do so. 
The remedies disagreed with him sometimes, and he was unnecessarily timid 
about increasing the doses. He never took more than 42 grains iodide potash 
three times a day. A statement from this patient, in March, 1878, says that he 
considers himself well. 



Case VII. — Syphilis — Symptoms of Cochlear Disease — Slight Improvement. — 

Mr. , aged thirty. Seen at Manhattan Eye and Ear Hospital. Patient 

was perfectly deaf so far as the voice was concerned. Could not hear the 
watch with which he was tested at all. The vibrations of the tuning-fork 
were also not heard. All communication with him had to be held in writ- 
ing. He could hear finger-nails against the left ear after three weeks, and the 
tinkling of the street-car bells. In five weeks he could hear tuning-fork quite 
well with the left ear. Later he heard the watch j P g with the same ear. All his 
symptoms pointed to a disease of the labyrinth, and it was considered to be 
syphilitic. He had contracted syphilis a year before, and had been treated 
for it from the outset ; still he had had secondary symptoms. Six months later 
he felt so well that he gave up treatment. Then he was taken with violent 
pains in his head, and observed impairment of hearing and tinnitus. In a week 
his hearing was "all gone." He resumed anti-syphilitic treatment, but the 
deafness and tinnitus have remained. 

This patient was treated with mercury and potash in increasing doses, and 
carried out all directions faithfully for a long time. His general condition im- 
proved, but no change was evident in his hearing except that mentioned above. 
One day he came, saying that on the day before he had heard the word Mexico. 
On trial, he was found to hear this word every time it was spoken into his left 
ear. He did not hear any of the component letters of the word (as x or o) when 
spoken into his ear, nor was any other word ever found which he could hear. 
At this time he was taken with pulmonary hemorrhages, and specific treatment 
was stopped. He has been in failing health ever since. 

It is undoubtedly true that affections occur in syphilitic pa- 
tients (from suppression of the perspiration, for example), which 
would have occurred all the same had they not been syphilitic ; 
and yet the exposure or imprudence having- once caused the 
attack of inflammation, it immediately assumes the character 
of a syphilitic affection by reason of the syphilitic blood, whose 



618 SYPHILITIC DISEASE OF LABYEIXTH. 

increased flow to the part and the exudation go to constitute the 
inflammation. The complete failure of the anti-catarrhal treat- 
ment, although all these patients showed some catarrhal symp- 
toms, was another striking evidence of the real nature of the 
cases ; for we seldom meet with cases of catarrh that do not 
respond to some extent to the use of the catheter, Politzer's 
method, and so forth, while in acute or sub-acute diseases of the 
labyrinth, this treatment often aggravates the symptoms. 



CHAPTER XXII. 

DISEASES OF THE INTERNAL EAR— (Concluded). 

The Effects of Quinine. — Cerebro-spinal Meningitis. — Meningitis. — Disease of the 
Spinal Cord. — Parotitis. —Acute Inflammation of Membranous Labyrinth mistaken 
for Cerebro-spinal Meningitis. — Hemorrhages and Effusions. — Injuries. — Concus- 
sions.— Aneurism and Tumors. — Disease of Semi-circular Canals. — Pathology. — 
Treatment. 

THE EFFECTS OF QUININE UPON THE LABYRINTH. 

In a paper read by me before the Society of Neurology and Eleo 
trology in April, 1874, l I classified four of the cases of disease of 
the internal ear then reported, as perhaps cases of congestion 
and inflammation of the base of the brain and labyrinth, caused 
by the internal administration of quinia. My remarks at that 
time led to a discussion, in which L)r. Jacobi and Dr. Hammond 
participated. To attempt a settlement of some of the questions 
involved, I undertook some experiments upon the human sub- 
ject, as did Dr. Hammond upon animals. I believe these were 
the first experiments to determine the effects of quinine upon the 
ear. They have been followed by others, and considerable clin- 
ical experience has been published, as to effects of quinine' upon 
the eye as well as the ear, so that the views of the profession are 
now clearer than before the subject was thus opened up. 

I think large doses of quinine may cause temporary affections 
of the labyrinth, which are made known by tinnitus aurium and 
impairment of hearing. This congestion is not, however, con- 
fined to the membranous labyrinth, but it may also occur in the 
tympanic cavity and in the auditory canal. It is so well known 
that buzzing in the ear is caused by quinine, that many persons 
who are becoming gradually deaf from chronic catarrhal or pro- 
liferous inflammations of the middle ear. and who. as is the case 
with most other persons in our country, have taken some quinine 
in their time, jump at the conclusion that the quinine caused the 
impairment of hearing from which they suffer. Exact exam- 
ination often shows that many such patients have never taken 



American Journal of the Medical Soiences, vol. lxviii., p. 400. 



620 EFFECTS OF QUININE. 

quinine enough to cause, or even to cure any disease. I object, 
however, to the use of quinine in aural disease, in any considera- 
ble doses ; for I have been convinced by experimental and thera- 
peutical experience that it has a peculiar power of producing 
congestion of the ear. In 1874 1 I published a case, which is re- 
produced on page 168, which proves this. My experiments with 
quinine upon the healthy human subject were begun upon Dr. 
William A. Hammond May 7, 1874. 

The optic papillse and the membranae tympanorum were the 
parts examined, as well as the ocular conjunctivae and auricles. 
" The vision was normal, f#. Refraction, emmetropic ; pulse, 
90 ; ocular conjunctivae white, decidedly free from hyperaemia ; 
palpebrae congested at outer and inner canthus. There was no 
tinnitus aurium. Membranae tympanorum were entirely free 
from evidence of blood-vessels. (I will omit the details of the 
examination of the optic papillae, since we are concerned only 
with the effect of quinine upon the auditory apparatus.)" 

Dr. Hammond took gr. x. of sulphate of quinine at 8.30 p.m. 
At 9 p.m. the ocular conjunctivae were congested at the outer 
and inner canthus ; palpebrae conjunctivae were markedly con- 
gested over the whole surface. There was no change in appear- 
ance of the drum-heads. 

" 10 p.m. — Head feels full ; left ear rings ; auricles burn ; face 
is decidedly flushed ; auricles are red, especially the lobe of right, 
where there is a localized congestion so marked as to resemble 
an ecchymosis. There is now a vessel along each malleus. The 
optic papillae are pinkish from apparent enlargement of lateral 
vessels. 

" 10.30 p.m. — Right drum-head is very much injected along the 
handle of the malleus and the upper margin ; left is less red, 
but still shows vascular injection. Both papillae are pink, left 
more so than right ; face flushed, eyes suffused, ocular conjunc- 
tivae decidedly congested, slight headache, tinnitus in both ears. 

"11 p.m. — The redness of the auricles is diminishing, espe- 
cially the circumscribed spot on the lobe of the left one ; the face 
still flushed ; tinnitus continues ; no headache ; subject feels 
exhilarated ; drum-heads still injected along the malleus ; vision 
normal." 

It should be said that Dr. Hammond, the subject of these 
experiments, is a very large and well-developed man, and that 
he smoked a mild cigar during the evening. 

On May 28, 1875, I repeated the experiment upon Dr. E. 
T. E , aged twenty-four, a man of about five feet six inches 

1 Transactions of the American Otological Society. 



EFFECTS OF QUININE. 621 

in height, well developed, in good health and vigor. He stated 
that he never had had otitis. The hearing distance is || on 
each side ; refraction emmetropic. He has no tinnitus aurium. 
The drum-heads are free from vessels, and normal in appear- 
ance ; optic papillae normal. At 11.05 a.m. Dr. E takes gr. x. 

of sulphate of quinine. At 11.35 there is a very fine vessel 
along the right malleus ; no change in the left. At 12.30 there 
is some redness at the periphery of the left drum-head, but the 
vessel on the right has disappeared. At 1 p.m. the redness has 
disappeared from both sides. No change is observed in the 
optic papillae. There is no tinnitus, and no sense of exhilara- 
tion. No tobacco or other stimulant was used during the time 
of observation. 

June 23, 1875. — Dr. C , aged twenty -five, about five feet 

nine inches in height, rather spare. Refraction myopic, ^ v. = 
|f. Drum-heads absolutely free from congestion. No vessel on 
or along malleus. Optic papillae are both flushed. 

At 10.16 a.m. takes gr. xv. of sulphate of quinine. 11 a.m., a 
vessel is seen along malleus of right membrana tympani ; and 
left membrana tympani presents no change. There is slight 
vertigo. 11.30. — There is a sense of heat and tingling over the 
whole surface of the body. Sense of fulness in ears and head. 
The handles of both mallei are injected. The hands are tremu- 
lous, and the subject gives general evidence of nervous excite- 
ment. There are sounds of a high note in the ears. The ears 
feel warm. At 12.30 the injection of the malleus is disappear- 
ing, as are the vertigo and tremor. At 12.50 the mallei are still 
injected. Motions of the jaw cause peculiar and unpleasant 
sense of vibration in the ears. 

Although these experiments are but three in number, they 
are sufficient, I think, to justify the view I expressed in the 
American Journal of the Medical Sciences, October, 1874, that 
the effects of quinine upon the ear were due to congestion. 
That view was contested at the time of reading the paper. 1 by 
Professor Jacobi, on the ground that some observations that had 
been made in Germany, as well as clinical experience, seemed 
to show that anaemia, and not congestion, was one of the effects 
of the use of quinine ; that is to say, it was claimed that con- 
traction and not dilatation of the vessels was produced by the 
drug. Dr. Hammond's experiments upon animals, and. what is 
much more conclusive than even experiments upon animals, 
large clinical experience, some of which is given us by such 
observers as the late Von Graefe. 2 confirm the view deduced 



New York Society of Neurology and Eleetrology. 
Archiv fur Ophthalmologic, Bd. III. 2, p, 896. 



622 EFFECTS OF QUINIXE. 

from my observations, that the tinnitus aurium following the 
use of quinine is the result of overfilled blood-vessels, and is not 
the anaemia of blood-vessels not containing the normal quality 
or quantity of fluid. 

It should also be stated, that I have experimented upon two 
other physicians, giving each ten grains of quinine at a dose. 
I have no notes of these cases, but I may say that in one case 
congestion of the drum-heads and of the optic papillae followed, 
with tinnitus aurium, while in the other absolutely no effect teas 
produced. The former subject w^as a full-blooded man who had 
suffered from congestion of the cerebral meninges. The gentle- 
man upon whom no effect was produced had been in the habit 
of taking quinine, and was rather anaemic. 

Dr. Hammond 1 published some experiments on this subject 
in a paper in which he gives the literature of the subject, and 
particularly the experience of M. Melier (Experiences et Ob- 
servations sur les Proprietes Toxiques du Sulfate de Quinine. 
Memoires de VAcademie Royale de lledecine, etc., p. 722). Melier 
is very decided as to quinine causing deafness, as are other 
writers ; but observations as to the immediate effect of the drug 
upon the membrana tympani or other parts of the ear do not ap- 
pear, except in the account of Dr. Hammond's own case. 

The observations that have been made upon the fundus oculi, 
after the administration of large doses of quinine, indicate that 
the secondary effect of toxic, or large doses of this drug, is to 
empty the blood-vessels. It has been assumed, I think, that is- 
chaemia of the retina is the first consequence of a poisonous or 
large dose. But the fundus oculi has not yet been examined in 
such cases, as soon as the loss of vision occurred. 

The following case reported by me, 2 awakened such attention 
to the effects of quinine upon the eye as well as ear, that the 
experiments upon animals were continued, and clinical reports 
were furnished from various sources. They have, as it seems 
to me, nearly all served to confirm the views, that I was the first 
to clearly express, as to the possible danger from the use of this 
drug, and the opinion that congestion is the primary effect of a 
large dose. 

A Case of Poisoning from the use of the Compound Tincture of Cinchona, producing 
Permanent Contraction of the Visual Fields and Temporary Impairment of Sight 
and Hearing. 

On July 3, 1878, Dr. L. M. Yale asked ine to see a case of loss of sight, of 
which the following history was obtained : Mr. B , aged fifty, a man of very 

1 Psychological and Medico-Legal Journal, October, 1874, p. 232. 

2 Archives of Ophthalmology, vol. viii. , p. 392. 



EFFECTS OF QUININE. 623 

intemperate habits as regards the rise of alcohol. He had been accustomed for 
years to drink enormously of brandy and whiskey at intervals, but there were 
periods of varying length, from one to three or four months, of total abstinence 
from intoxicating drinks. 

Mr. B was told that the use of the tincture of cinchona would relieve 

him from his periodic craving for alcohol. On June 24th of that year he began 
its use, with a view of correcting his intemperate habits. On that day, as 
well as on the 25th, 26th, 27th, and 28th, he continued to take the compound 
tincture in ounce and two-ounce doses, at short intervals, literally drinking it as 
a beverage from a quart bottle, in which he had caused an apothecary to place as 
strong a preparation as possible. On the 28th, although he had taken none of 
his ordinary alcoholic stimulants, his clerk thought from his conduct that Mr. 

B had been drinking heavily. Dr. Yale estimated that in these days the 

patient took an amount of the tincture which would be equivalent to 125 ' grains 

of an alkaloid of cinchona. Mr. B has no recollection of any occurrence 

after the 27th. He is confident that he took no alcohol, except that contained 
in the preparation of cinchona, during these days. This, however, may be 
doubtful, for the clerk of the hotel to which he went when in what proved to 
be a semi-conscious state on the 28th, states that while he lay in bed he was 
constantly ringing the bell for liquor. It is possible that during this time some 

doses of alcohol were added to those of cinchona, although Mr. B does not 

believe this to be the case. On the morning of July 1st he was seen by Dr. 
Hills in the absence of Dr. Yale. He found the patient stupid or half -conscious, 
with flushed face and conjunctivae, and apparently unable to see or hear. Mr. 

B remembers Dr. Hills' visit on Sunday, and knows that he was then blind 

and deaf. Dr. Yale saw the patient on Monday and Tuesday, July 2d and 3d. 
His hearing power improved so much in that time as to become apparently nor- 
mal, but his vision remained very much impaired. On the day I saw Mr. B — ■ — , 
the 3d, he was groping about his room, apparently in excellent general health and 
with good hearing. V., E. E. = quantitative perception of light. L. E. counts 
fingers at one foot. The ophthalmoscope showed lessened size of the arterial 
vessels ; no abnormity in the veins, lessened number of vessels on the papilla?, 
but no marked paleness. No changes observed in the membrana tympani. The 
patient was advised to take strychnia in increasing doses and nutritious diet. 
On July 6th he was able to walk about. V. = \% each eye, but the visual fields 
were very much contracted, so that vision was telescopic. 

On July 16, 1878, both visual fields were found concentrically limited. The 
measurements, drawn on a blackboard 14" distant, were as follows : Bight field, 
vertical, 9 inches ; horizontal, 7| inches ; limitation most marked on temporal 
side. Left field, vertical, 7 inches ; horizontal, 8 inches ; limitation more 

regular. B found this symptom rather novel than troublesome. The optic 

papillae looked very pale, and the arteries were narrow. July 23d, V. = |$, each 
eye. Patient states that he can see perfectly well in a straight lino, but that 
when walking about a room he has some difficulty in seeing small articles of 
furniture. 

September 10th. — The same condition is maintained. The strychnia was 
taken until -, 1 ,, grain had been reached at a dose, and was continued for two 
months. The visual field remains as on July 16th. 

1 This amount was afterward found to bo nearer 509 grains. 



624 EFFECTS OF QUIXIXE. 

April 23, 1879. — Mr. B 's condition remains substantially the same. He 

continues to abstain entirely from the use of alcohol, and carries on a large busi- 
ness successfully. His vision is still fg each eye. The visual field has increased 
somewhat in the left eye. It now measures 9 inches vertically and 16 inches 
horizontally. F. of E. E. 6" vertically, 9" horizontally. Limitation most 
marked at upper-inner quadrant. The optic disks are pale and the arteries small. 
There are no other ophthalmoscopic appearances. 

Mr. B had taken no alcohol for some months prior to his 

beginning the use of the cinchona, and he took none until he be- 
came unconscious on the fourth or fifth day. Although he went 
about and transacted business on the fourth day, he has no rec- 
ollection of what he did. "When found he had an empty bottle 
(holding a quart) in his room, labelled and giving positive evi- 
dence of having contained cinchona. He certainly did not take 
many drinks, if any. after he reached the hotel, for the clerk, 
knowing his former habits, and supposing him to be suffering 
from an ordinary debauch, refused to answer his demands. It 
is not known that he took anything but the cinchona at anytime 
after he began the treatment of the alcohol habit. 

We have here. then, a case of hyperemia of the vessels of 
the ear from the use of cinchona and alcohol — a hyperemia 
which passed away without going on to an exudative process ; 
but the same condition in the vessels supplying the retina con- 
tinued until a true vasculitis, with its consequences, resulted. 

The following case was considered to be one of chronic catarrh 
of the middle ears, with affection of the cochlea. "While under 
treatment it happened to furnish an illustration of the effects of 
quinine upon the ears : 

Injury of the Cochlea from Cannonading — Effects of Quinine on the Ear. — Dr. 

P , aged fifty-one. In 1870 was exposed to heavy cannonading, after which 

he had sudden tinnitus and impairment of hearing on both sides. The symp- 
toms passed away in great measure within a short time. Since then he has had 
the tinnitus only occasionally. The deafness has not been enough to annoy him 
until lately. Thinks the right ear has always been the worse. A year and a half 
ago he noticed that he heard the click preceding the striking of his clock, but 
did not hear the strike. Xow he hears the strike, but not the click. Hears 
worse in a noisy place. Has been troubled with irritation and excess of secretion 
in pharynx for a long time. Health otherwise excellent. 

H. D.— E. E., - 4 V; L. E., ■&. Voice, fifty feet behind back. 

Tuning-fork placed on teeth is heard alike. Plugging either ear makes no 
difference. Placed on forehead or vertex is heard alike, but better on left side 
when plugged. Placed on mastoid heard better on left side than on right ; 
plugging left ear intensifies sound of fork ; plugging the right ear makes no 
difference. All the notes of the piano are heard well with the left ear. The 
right ear has partially lost its perception of some of the lower and some of the 
upper notes, but hears the others well. 



EFFECTS OF QUININE. 625 

Eight drum-head : Opaque. Light spot, narrow and divided. 

Left drum-head : Opaque. Good light spot. 

Pharynx catarrhal. 

Inflation for three weeks improved the hearing for the watch to -At on both 
sides. 

One morning, while under treatment, the patient came complaining of great 
"stuffiness" and tinnitus in both ears. During the preceding twenty-four hours 
he had taken thirty-eight grains of quinine for neuralgia. The hearing for the 
watch was -fa R E., and -fo L. E. There was intense redness along each malleus- 
handle. (The day before the hearing had been - 4 a - each side, and no redness of 
the drum-heads existed on that day, or had ever been seen before.) Inflation did 
not improve the hearing at all, although it had never failed to do so before. 
At the next visit the conditions were as usual. 

Several weeks after stopping treatment, the hearing had relapsed to its 
former state. 

In an inaugural dissertation Dr. Hans Brunner ' has collected 
the cases of amblyopia caused by quinine, and also gives the re- 
sult of experiments made with the drug. Until the observations 
of Briquet, Paris, 1855, who saw four cases of temporary blind- 
ness found in four persons from daily doses of from 3 to 5.0 
grammes, they are not of any importance. Briquet thinks that 
impairment of vision occurs less frequently than impairment of 
hearing. Dr. Virsinier, of Louisiana, quoted by Brunner, has 
seen deafness occur without blindness, but never blindness un- 
accompanied by deafness. One of his patients, during an attack 
of intermittent fever of a pernicious variety, took 4.0 grammes 
of sulphate of quinine within six hours, and just as much during 
the same time in an enema. On the next day the patient was 
deaf and blind. 

Dr. Baldwin, of Alabama, has warned the profession on sev- 
eral occasions of the dangers to sight, hearing, and even life, 
from large doses. 

Weber-Liel, 2 quoted by Brunner, verifies my views as to con- 
gestion of the ears being caused by quinine. Kirchner, 3 in an 
article upon the effects of sulphate of quinine upon the tempera- 
ture and circulation, states as the result of his experiments, that 
quinine causes inflammatory processes and permanent patholog- 
ical changes in the ear. He believes that the cause for these con- 
ditions is to be found not only in a hypercemia of short duration, 
hut also in paralysis of the vessels 'with congestion and exuda- 
tion. 

I believe that the tinnitus aurium and impairment of hear- 



1 Ueber Cliininamaurose. Dissenlioffen, 1882. "Loo. cit, p. 36, 

3 Berlin. Klin. Wochensohrift, L8B1, p. 725. 
40 



626 EFFECTS OF QUININE. 

ing, following the use of quinine, depend upon congestion of the 
ultimate fibres of the auditory nerve in the cochlea, and that the 
redness of the drum-heads is merely an index of the former con- 
dition. 

Up to the time of writing this, I have had no opportunity of 
testing a case of impairment of hearing caused by quinine, as to 
aerial and bone conduction. I predict that when such an exam- 
ination is made, it will be found that the tuning-fork, C 2 , in cases 
of impairment of hearing from quinine, will be heard better 
through the air than through the bones, and if there be absolute 
deafness for the voice, that it will not be heard either through 
the air or bones. 

Fortunately most of the cases of deafness caused by quinine 
fully recover. In some, however, most deplorable results occur. 
It is a drug that should never be lightly administered to any 
person, and especially to any one already affected with aural 
disease, unless in the rare cases of malarial neuralgia of the 
middle ear. 

Kirchner found diminution in the perception of a vibratory 
tuning-fork placed upon the bones of the head, and also a dimin- 
ished perception of the higher tones. Orne Green * on reviewing 
the literature of this subject and giving his own large clinical 
experience, quotes my views and their corroboration by Kirchner 
with approbation, and states : From our present knowledge, both 
clinical and experimental, we are justified in asserting that the 
action of quinine upon the ears is to produce congestion of the 
labyrinth and tympanum, and sometimes distinct inflammation, 
with permanent tissue changes 



DISEASE OF THE ACOUSTIC NERVES CAUSED BY CEREBRO-SPINAL 

MENINGITIS. 

Cerebro-spinal meningitis has been generally supposed to be 
the cause of many cases of disease of the auditory nerves. That 
it frequently causes great loss of hearing, and sometimes abso- 
lute deafness, no one with the least clinical experience will deny. 
A large proportion of the deaf-mutes of the present day are said 
to have lost their hearing in the course of cerebro-spinal menin- 
gitis. I believe, however, that although the trunk of the acoustic 
nerve and the labyrinth may become diseased, and perhaps pri- 
marily in some cases, that the lesion of the ear that most fre- 
quently occurs in the disease is an inflammation in the tympa- 
num. Judging from the analogous process that occurs in the 

1 Boston Medical and Surgical Journal, vol. cviii. , p. 220. 






CEREBROSPINAL MENINGITIS. 627 

eye, this seems a plausible view. We do not usually have optic 
neuritis when the eye becomes affected in cerebro-spinal men- 
ingitis, but choroiditis — a peripheric and not a central affection. 
The pathological investigations in this direction have been few, 
apparently because general pathologists are not much interested 
in the ear, and those who concern themselves with its diseases 
have few opportunities to make post-mortem examinations in 
cases of cerebro-spinal meningitis. The clinical facts are 
against the theory of disease of the nerves. There is scarcely 
ever facial paralysis in conjunction with the deafness. It is 
hard to conceive of suppuration of the trunk of the acoustic 
nerve, without any affection of the facial, and although this ab- 
sence of facial paralysis does not prove Yoltolini's view, nearly 
all the cases of loss of hearing said to result from cerebro-spinal 
meningitis, actually depend upon inflammation of the membran- 
ous labyrinth. It assists us to believe that the first lesion may 
often be in the tympanum. The evidence furnished by the drum- 
heads, which are so often sunken, although not conclusive — for 
we may have secondary disease of the tympanum as well as of 
the labyrinth — is another point in the clinical evidence. Then 
the tuning-fork, in many cases, notably in deaf-mutes, is heard 
through the bones, when it is not at all perceived through the 
air. Disease of the acoustic nerve has, however, been found 
in post-mortem examinations of cases of this disease. Wie- 
meyer, quoted by Moos, 1 remarks that he does not consider it 
improbable that "the deafness and impairment of hearing may 
be produced by different causes," but he states that Luschka, and 
himself, found the acoustic nerve, up to its exit from the skull, 
so completely imbedded in masses of exudation, that Professor 
Luschka felt justified in supposing that the inflammation and 
exudation following the course of the nerves might easily, in 
some cases, extend into the labyrinth. Moos, in this same 
paper, gives a report of the necroscopy of two cases in which 
there was found pus in each tympanum, also in the vestibules, 
and ampullae, and the cochlea. Both the acoustic and facial 
nerves in the meatus auditorius were surrounded by pus. The 
second case presented similar appearances. 

It has been pretty generally assumed that these cases were 
cases in which the trunk of the acoustic nerve was primarily 
affected, but it is by no means certain that the primary trouble 
here also was not in the tympanum whence it may have ex- 
tended to the labyrinth and nerve. 

The cases reported by Heller a show that he considers it pos- 

1 Archives of Ophthalmology and Otology, vol. Li., p, 628, 
8 Archiv fur Ohrenheilkunde, Bd, IV., p. 55. 



628 CEREBROSPINAL MENINGITIS. 

sible, from his microscopic examinations, that the suppuration 
in the tympana and labyrinth may have occurred simultane- 
ously with the changes in the cerebral and spinal membranes. 
Lucae ' reports a case which more fully supports the view of a 
primary affection of the labyrinth in cerebro-spinal meningitis 
than do any of the preceding cases. In his case there was 
merely congestion of the tympana, while the Eustachian tubes 
were in a normal condition and the labyrinths were in a state 
of suppuration. " The purulent inflammation of the base of the 
brain along the vessels of the acoustic nerve up to the cochlea, 
was more exactly traced on both sides." Knapp 2 found " symp- 
toms of hyperemia or catarrhal inflammation of the middle ear, 
either during the febrile stage of the disease or during the period 
of convalescence" in many cases. Knapp also examined two 
temporal bones of a patient who had become deaf and died from 
cerebro-spinal meningitis. In one ear the outer and middle ears 
were normal, while the acoustic nerve was softened by suppu- 
ration. While the accompanying facial appeared to be normal, 
the acoustic nerve of the other side had not suffered, but numer- 
ous pus-cells were found around it. The labyrinth was not ex- 
amined. 

Moos, 3 however, reports the post-mortem of a case of cerebro- 
spinal meningitis, in which the nerve was found to be sound, 
excepting some congestion of the sheath up to the meatus audi- 
torius internus, while there was extension of the inflammation 
from the dura mater into both tympanic cavities. 

Von Troltsch says that a few post-mortem examinations 
show that the morbid changes causing deafness in cerebro- 
spinal meningitis, are sometimes found in the fourth ventricle. 

Professor J. Lewis Smith 4 says that "inflammation of the 
middle ear, of a mild grade and subsiding without impairment 
of hearing, is common." Dr. Smith also says that suppuration 
of the tympanum may occur. According to his statistics, about 
one in every ten patients becomes deaf. 

I have seen congestion of the tympanum in recent cases of 
the disease under discussion, and I have seen many where the 
labyrinth was the seat of disease, but whether primarily or sec- 
ondarily so, I cannot say. It is probable that the inflammatory 
process sometimes, and, as I think, generally, follows the blood- 
vessels into the tympanum rather than along the acoustic nerve, 
for in most of the cases I have seen there is still some hearing 

1 Arcliiv fur Ohrenheilkmide, Bd. V. , p. 188. 

2 Transactions of the American Otological Society, 1873. 

9 Archives of Ophthalmology and Otology, vol. iii. , No. 2, p. 177. 
4 Medical Record, December 8, 1883. 



CEREBRO-SPINAL MENINGITIS. 629 

power by bone conduction, to me a positive indication that some 
power remains in the acoustic nerve. 

The following cases illustrate the clinical appearances : 

Case I. — Cerebro- Spinal Meningitis — Bilateral Deafness — Both Drum-Heads 

Sunken. — December 30, 1869. R. M. W , aged thirteen, five years ago this 

winter had an inflammatory disease of the head and joints, and when he recovered 
from this affection became deaf. He does not hear words in any way. He feels 
the tuning-fork placed on the bones in each ear. The membrane tympani of both 
sides are sunken ; the pharynx and nares are in a healthy condition ; air enters 
both tympanic cavities. 

Case II. — Cerebro-Spinal Meningitis — Absolute Deafness — Both Drum-Heads 

Sunken. — C. M , boy, aged four years and eight months, heard and talked 

well until about a year ago, when he had a fit of sickness, which the parents de- 
scribed very imperfectly, but which was attended by some loss of power in the 
limbs. There was at one time some discharge of pus from one of the ears. The 
child does not seem to hear sounds at all ; the vibrations of a large tuning-fork 
are not perceived. Both drum-heads sunken and pinkish. 

Case III. — Cerebro-Spinal Meningitis — Deafness Absolute — Membranai Tympani 

Normal. — May 22, 1872. D. W. K , aged twenty-one, a little more than three 

months since was attacked by some disease of the head, and for two weeks was 
stupid or delirious. There were some little spots on the neck. When he be- 
came conscious, he could not hear ; he has remained deaf ever since. There 
seems to be absolutely no hearing power ; cannot hear the voice even when con- 
veyed to the ear through a tube ; and is equally unconscious of the sound of the 
tuning-fork or the piano. The membranse tympani are of normal color, trans- 
parency, and position ; air enters the tympanic cavities. 

Case IV. — Cerebro-Spinal Meningitis — Sunken Drum-Heads. — George S , 

aged twenty-five months, when fourteen months old had congestion of the brain ; 
was unconscious, paralyzed, and had spots on the skin. Was found to be deaf 
when he recovered. Both membranse tympani are sunken. 

Case V. — Cerebro-Spinal Meningitis — Sunken Drum-Heads. — May 31, 1873. 

John D •, aged nine, eight weeks ago to-day was seized with a pain in his head 

at about 8 o'clock a.m. The pain was said to be across the forehead. At 11 
o'clock he had convulsions. There was spasm, especially of the hands and 
throat, at 8 p.m. ; complained of headache, and at 11 p.m. he vomited. He be- 
came unconscious, and remained so until 4 a.m. Ten days after the attacks he 
was deaf, and still continues to be so. He states that there is a whistling sound 
in his ears. He took large doses of quinia, and soon recovered from all the symp- 
toms, except a little uncertainty in his steps, and even now he has a somewhat 
tottering gait. He does not hear the watch at all ; but can distinguish sounds 
conducted into his ear through a tube. The tuning-fork, when placed upon the 
teeth, produces a buzzing noise. The drum membranes are very much sunken, 
and of a pinkish hue ; show a small light spot. 

Case VI. — Cerebro-Spinal Meningitis — Normal Membranm Tumpani — Slight 
Amount of Hearing Power as 'rested by Piano. — March 17, 1871. D. B , aged 



630 MENINGITIS. 

twenty-one, a little more than ten months ago was attacked with a chill, which 
was attributed to sitting upon a stone in the front of the house during the month 
of May. After the chill the patient became delirious, and his neck was stiff, and 
he had no use of his arms or legs. This state of things continued for one week. 
As soon as he became rational he was found to be deaf, and his left side re- 
mained paralyzed. He gradually recovered from the paralysis, though his deaf- 
ness continues, and he staggers in his walk. Hearing distance : right 0, left 0. 
The tuning-fork is faintly heard in both ears ; he is sensible of the tones of his 
own voice, and talks in a natural tone, modulating fairly. He thinks his right 
ear is the better one. By means of a conversation tube connected with the 
keys of a piano, he is enabled, through the medium of the right ear, to distin- 
guish the C, D, and E of the treble, as well as all the bass notes. "With the 
left ear he cannot distinguish the treble, the bass notes alone being audible. 
This is in accordance with the law of acoustics, that the impression of the bass 
or low notes remains longer on the ear, thus proving that the patient had still 
a slight trace of hearing power remaining in the cochlea, and that the state- 
ment that he heard better with the right ear was correct. The membranae 
tympani are transparent, the pharynx is granular. The patient has been for 
some weeks under competent treatment, but without perceptible benefit. 

Case VII. — Cerebro-Spinal Meningitis — Normal Membranoe Tympani. — May 2, 

1872. Virgil T , aged five, four weeks ago was seized with a severe pain in 

the head ; soon vomited, and was delirious at times, especially on waking from 
sleep. He complains of pain in the back and neck, and also of pain in his right 
ear. Four days after the attack began he was found to be deaf, which symp- 
tom increased after a second attack of pain. Apparently there is an entire ab- 
sence of hearing power. There is nothing marked in the appearance of the drum 
membranes. He totters in his gait. 



INFLAMMATION OF THE ACOUSTIC NERVE AND LABYRINTH FROM 

MENINGITIS. 

It is well known that inflammation of the base of the brain 
may extend to the trunk of the acoustic nerve and to the laby- 
rinth. The following cases are examples of this form of disease 
of the internal ear : 

Case I — Meningitis — Gradual Deafness. — June 25, 1870. "W. K. J , aged 

twenty-seven, complains of increased impairment of hearing. Had scarlet fever 
when a child, after which he felt a diminution in the hearing power. Last winter 
had congestion of the brain and hemiplegia of left side. His right ear became 
decidedly worse at this time. He has recovered from the hemiplegia. There is 
no tinnitus aurium. The hearing distance on the right side 0, left if. Tun- 
ing-fork is heard better on right side. The right membrana tympani is sunken, 
and has no light spot. The left is also sunken, and exhibits two reflections of 
light. Inflation of the ears improves the hearing on the left side. 

Case II. — Basilar Meningitis — Bilateral Deafness. — April 30, 1872. William 
B , aged twenty-seven, says that seven weeks ago he could hear well, but 



MENINGITIS. 631 

after an attack of fever attended by delirium, he found, when restored to con- 
ciousness, that he had lost his hearing. There is a roaring noise in the left ear, 
but no other aural symptom. He can hear the watch when laid upon the right ear, 
but not at all upon the left. The tuning-fork is also heard more or less distinctly 
in the right ear. The light drum-head is somewhat sunken, the left very much so. 

Case III. — Meningitis — Inflammation of Cerebral Meninges and Labyrinth — Ex- 
posure to Direct Rays of the Sun. — September 8, 1873. Laura , aged twenty- 
two months. The mother states that when the child was eight months old, and 
teething, she was unduly exposed to the direct rays of the sun, and was there- 
upon suddenly attacked with convulsions and was ill for three weeks afterward. 
The physician in charge observed that she was losing her hearing, and the mother 
thinks that she has not heard since that period. The drum-heads are both very 
much sunken and have no light spot. 

Case TV. — Basilar Meningitis — Effusion about Auditory Nerve — Intermittent 
Character of Attacks — Epilepsy — Deafness — Recovery. — January 29, 1874. Moses 

B , aged twenty-nine, merchant, previous to July last heard perfectly well. 

He has had intermittent fever at different times for two years ; had also an attack 
of sunstroke. In July he lost the hearing in one ear, and for four weeks he was 
deaf with both ears. After a course of counter- irritation his hearing gradually 
returned. He has taken a large quantity of quinia. Some weeks ago, while at 
Petersburg, Va., his hearing power again failed, and at the present time he can- 
not hear words at all ; even the ticking of the watch is not perceived. He can- 
not hear the tuning-fork when placed upon the head, but feels it when on the 
teeth. The drum-heads are somewhat opaque, and there is granular pharyn- 
gitis. He complains of a severe pain in the top of his head, and of a knocking 
sound in the interior. His countenance is very anxious, appetite poor, but he 
walks well. There is no history of syphilis. He had a severe fall upon his 
head, striking the occipital region, when he was seven years of age. I saw the 
patient first at my clinic at the University Medical College, and the next day at 
my office in consultation with his family physician. I advised iodide of potas- 
sium, but I did not see him again for two months, when, at the instance of Dr. 
William A. Hammond, he called upon me, and to my great delight I found that 
he could now hear conversation with ease, and the watch at twenty inches ; 
hearing distance f$ on each side. He had been under Dr. Hammond's care for 
about four weeks. 

Dr. Hammond treated the case by means of the iodide of 
potassium mixed with the bromide. This treatment relieved 
the cephalalgia and epilepsy. Subsequently he administered 
arsenic in consequence of the intermittent type of the epilepsy. 
The hearing power was suddenly restored on one side, and the 
other soon became better also. 

Through the courtesy of Dr. H. G. Miller, of Providence, I 
have been furnished with the following interesting history, and 
I was also afforded the opportunity of seeing the ease : 

Case V. — Meningitis — Inflammation of Both Auditory Nerves — Recovery of 
One. — December 29, 1873. II. S , a student of Trinity College, early in Octo- 



632 DISEASE OF SPINAL COED. 

ber had an acute affection of the cerebral meninges and of internal ear, leaving 
him totally deaf in one ear, and nearly so in the other. I saw him first about ten 
days after the commencement of the trouble. His condition then was : External 
and middle ears perfectly normal ; subjective noises very troublesome, and ex- 
treme giddiness on walking, and especially on attempting to go down-stairs, and 
also on turning the head in either direction. Hearing distance : right ear, contact 
for a watch of 30 ' ; left ear, 0. Tuning-fork heard by bone conduction in right ; 
not at all in left. I put him on bromide and iodide of potassium, and soon began 
the use of the constant current. The light ear improved rapidly, and in about 
five weeks hearing distance became normal. For some time after that, however, 
through the two octaves of the piano, from middle C upward, he heard, in addi- 
tion to the note struck, another less than a semitone above, which produced a 
most disagreeable clang, and rendered music very unpleasant to him. I then 
saw Dr. Blake in consultation about the left ear. We found in it perception for 
higher sounds than normal, and that this perception was prolonged by the con- 
tinued current ; and advised the continuance of the electricity, and also the use 
of valerianate of zinc and conium. Since that time there has been but little 
change. He has at times heard the watch faintly, but cannot always be sure of 
it. The auricle of the affected ear was quite numb. No further treatment was 
advised. 

Case VI. — Meningitis — Deafness — Normal Membrance Tympani. — Sallie A , 

aged thirteen, three months ago was attacked with severe headache and vomiting; 
delirium at times, but generally consciousness retained. In three weeks the fever 
subsided. There was no paralysis. She did not hear well after being ill a few 
days. Was attacked on Saturday, and on Wednesday it was observed that she 
did not hear words, even when spoken very close to her. The patient com- 
plained then, as now, of severe tinnitus aurium ; does not hear the watch at all. 
The tuning-fork is heard well and naturally. Jarring sounds hurt her head. 
There are no marked changes on the membrana tympani. 



INFLAMMATION OF THE INTERNAL EAR FROM DISEASE OF THE SPINAL 
CORD AND MEDULLA, TYPHOID FEVER, AND SCARLET FEVER. 

I have seen several cases of locomotor ataxia, in which there 
was considerable impairment of hearing. In these cases the 
cause has not usually been a coincidental catarrh of the tym- 
panum, but an affection of the acoustic nerve. The tuning-fork 
was heard better through the air, the voice better than the watch, 
noises were distressing, and the hearing was made worse by 
inflation. I have watched one such case for some eight years, 
and although the general symptoms of the patient have some- 
what increased — that is, his locomotion is not so good, and his 
nutrition is more impaired — the hearing power remains about the 
same. With the same degree of disease of the middle ear, he 
would by this time have been much worse. 

Typhoid fever sometimes produces disease of the middle ear, 
sometimes of the labyrinth, and occasionally of both parts in 



SCARLET FEVER — CEREBROSPINAL MENINGITIS. 633 

the same subject. There is apparently an anaemia of the laby- 
rinth, after certain cases of continued fever, for while the symp- 
toms are those of disease of the nerve, they partially recover as 
convalescence goes on. In some cases it is possible that the dis- 
ease of the labyrinth is caused or increased by quinine which 
has been given during the illness. 

Scarlet fever usually causes a suppuration of the middle ears, 
and no further disease, but in some rare instances the inflamma- 
tion is not suppurative and attacks the labyrinth. 

Case I. — Scarlet Fevet — Deafness — JSFo Changes in the Pharynx or the Outer 

Ear. — January 28, 1870. S. M. J , aged five, had a mild attack of scarlet fever 

when he was eight months old ; the mother discovered that the child was deaf 
four months afterward. There appears to be no hearing power. The tuning- 
fork causes no sensation. The pharynx and nares are in a healthy state, and the 
membranaa tympani show no changes. 

In not extremely rare instances, as it appears from the tables 
of institutions for the deaf and dumb, pneumonia causes diseases 
of the internal and middle ear. Very lately I have seen, in con- 
sultation with Professor J. L. Little, a case where deafness fol- 
lowed pneumonia which followed a mild attack of cerebro-spinal 
meningitis. 

Case II. — Cerebro-spinal Meningitis (? ) — Pneumonia — Profound Deafness — 

Sunken Drum-Head. — November 27, 1883. Maggie K , aged five. Dr. Little's 

account of the case was as follows : " This child was taken sick about two weeks 
ago, with symptoms that pointed toward cerebro-spinal meningitis. On the fifth 
day these symptoms subsided and an examination showed pneumonia of the left 
lung. Two years ago she had a similar attack. She now seems to be deaf.'' 
The father stated that the child had been deaf for a week ; she complains of 
tinnitus in her left ear. When the child was taken sick, she had fever and fre- 
quent vomiting. The latter symptom occurred for two days. On the fifth day 
pneumonia appeared. She recovered, -and while convalescing one week ago, 
deafness came on. She does not hear the voice or loud sounds conveyed through 
the air. It is impossible to learn whether she hears the tuning-fork by bone or 
not. Both drum-heads are sunken, and the left is congested and exhibits two 
light spots. Treatment was of no avail. On June 4, 1884, 1 saw her again. She 
was deaf to all sounds through the air, but seemed to hear the vibrations of the 
tuning-fork when placed upon the bones. This, I think, was a metastatic in- 
flammation of the middle and internal ears, but I think the disease began in the 
tympana, and that some degree of power remained in the nerve. It is a case 
which throws some light upon the nature of aural disease in eerebro-spiual men- 
ingitis. 

DISEASE OF THE INTERNAL EAR FROM PAROTITIS. 

Of a total number of 5000 cases of aural disease, seen in pri- 
vate practice, of which I have notes, only 10 seemed to have 
been caused by parotitis. Specialists in this country ami in 



634 DEAFNESS FROM PAROTITIS. 

Germany have seen very few of such cases. Of late great in- 
terest has been shown in this subject, as shown by cases re- 
ported by Buck/ Brunner, 2 Knapp, 3 Moos, 4 Harlan, and others, but 
very little has been added to the statements of Toynbee, Hinton, 
and myself, made by the first-named author in his text-book, in 
1860, by Hinton, in 1874, in his "Questions of Aural Surgery," 
and by myself in an article on "Diseases of the Internal Ear," 
in the American Journal of the Medical Sciences. Toynbee and 
Hinton, and lately Dalby, speak of disease of the ear after 
mumps as if it were a common one. In this they differ from 
the German and American authorities, who speak of it as a rare 
affection. Hinton says : "Next, or perhaps equal, in frequency 
to scarlatina, in this respect, stands mumps, which has an effect 
on the nervous apparatus of the ear which has as yet received 
no explanation, and affords no clue to the use of remedies ; 
every part of the ear being normal, so far as examination can 
extend, but the function is almost abolished. ' But some cases 
(the italics are mine) of damage to the ear from mumps present 
an intermediate character, showing clear signs of a tympanic 
disorder mixed with the nervous symptoms. The similarity of 
the nerve affection that follows mumps to that tvhich ensues 
upon parturition, is very striking ; and the resemblance is in- 
creased by the fact that quite frequently the latter affection also 
is accompanied with symptoms of a catarrhal character.' " 

After all that has been written, it still remains doubtful as 
to how the ear is invaded, and whether the disease is generally 
a primary one of the labyrinth or of the middle ear. That it is 
occasionally at least a disease of the middle ear, the last of the 
cases reported by me, 6 and here reproduced, plainly shows. The 
first cases which I reported were observed before I knew the 
full value of the tuning-fork in diagnosis, and I am unable to 
say of some of them whether they are cases of disease of the 
internal or middle ear. 



Case I. — Parotitis — Deafness of One Side — Patient first seen Three Tears after 
the occurrence of the Mumps. — H. A. H , aged twenty-three, student of medi- 
cine. Three years ago the patient had a slight attack of the mumps. During it he 
lost the hearing of the right ear. Hearing distance : B., -ff- ; and L., ff. The 
membrana tympani appears to be normal. There is considerable tinnitus aurium. 
The patient was treated through the Eustachian tube for about two months. 



1 American Journal of Otology, vol. iii., p. 203. 

2 Archives of Otology, vol. xii. , p. 102. 

3 Ibid., vol. xi., p. 385. 4 Ibid., p. 13. 
5 Archives of Otology, vol. xii. , p. 1. 



DEAFNESS FROM PAROTITIS. 63U 

The tinnitus was usually diminished for an hour or so after the applications 
through the catheter. 

In this case there was certainly disease of the middle ear. It 
will be observed that the watch was heard upon the mastoid 
process, while not upon the meatus. The case was seen in 1866, 
when I was not aware of the value of the tuning-fork in making 
a differential diagnosis of disease of the middle ear. Yet, from 
the results of the treatment, I am confident that there was an 
affection of the middle ear ; also the nerve may have been af- 
fected. 

Case II. — Disease of Labyrinth of One Side after Parotitis — Patient first seen 
One Year after Loss of Hearing occurred. — June 14, 1871, MissB , aged twenty- 
one. Patient states that she had the mumps one year ago. After recovery, she 
observed a buzzing sound like that made by insects. She has not heard with 
the ear since. At this time there is an unpleasant fulness in the ear. 

The hearing distance from the right ear is normal. From the left, it is -<&-. 

The membranae tympani are normal. The tuning-fork is heard only on the 
right side. 

The patient was seen again in September of the same year. She then stated 
that she had vertigo occasionally. In other respects the condition was the 



The evidence is clear that the labyrinth was the chief, if not 
the only, seat of the aural disease in this case. The foregoing 
cases are those published in the American Journal of the Medi- 
cal Sciences, loc. cit. 

Case III. — Disease of Labyrinth of Both Sides after Scarlet Fever, Measles, 
and Mumps — Patient first seen Thirty-one Years after Loss of Hearing occurred. — 

September 15, 1873, Henry N. X , aged thirty-four. The patient states that 

when two or three years old he had the measles, scarlet fever, and mumps in 
one year, and that his hearing has been defective ever since. He never had any 
discharge from the ears, and he rarely had tinnitus. 

H.D., E. - 4 ^; andL., ^ (?). 

The tuning-fork is heard better on the better side. The right drum-head is 
somewhat sunken. The left one looks well. 

Inflation of the middle ear produces no change in the hearing power. 

The meagreness of the history does not enable me to say 
whether the loss of hearing was observed immediately after the 
attack of parotitis, or after the measles, or scarlet fever. The ab- 
sence of ulceration at any time, however, inclines me to believe 
it to be a true case of loss of hearing as a result of parotitis. 

Case IV. — Impairment of Hearing of Left Ear, occurring during attack of 
Parotitis — Disease of Bight Ear had occurred previously from Scarlet Fcrcr - 
Patient first seen about Five Months after attack of Mumps. — October 1, 1875, 



636 DEAFNESS FROM PAPwOTITIS. 

Mrs. J. S. C , aged about thirty-five. The patient states that she had scar- 
let fever at the age of eighteen. She has suffered from greatly impaired hearing 
on the right side ever since. Last May she had the " mumps." During the 
course of the disease, she found that she was deaf in the left ear. She heard 
well on one day, and the next day she found herself deaf. There was no pain 
in the ear, and no discharge from it. She has suffered from tinnitus aurium 
since. She hears the watch on the right side (on that of the ear deaf from scar- 
let fever), 1M, L. ear when pressed upon the mastoid, J|. She has nasopha- 
ryngeal catarrh. Both drum-heads are of good color, and have good light spots. 

The diagnosis made was disease of the middle ear on the 
right side and disease of the labyrinth on the left. The grounds 
for the diagnosis of the labyrinthine disease are, however, not 
given, except in the statement that the deafness occurred sud- 
denly, and that inflation caused no improvement in the hearing. 
Unfortunately, I do not remember the case with enough clear- 
ness to give any more detailed account of the reasons for be- 
lieving that the ear affected by scarlet fever was chiefly so in 
the middle part, while the other had a lesion of the nerve. 

Case V. — Impairment of Hearing of One Side after Mumps— Inspissated Ceru- 
men — Hearing Improved after its removal — Patient first seen Ten Years after the 

Parotitis had occurred. — October 12, 1875, C. H. T , aged twenty-eight. The 

patient states that he had the mumps ten years ago. After that he observed 
that the watch was heard better in front of the right ear than of the left. He 
did not regard the condition of his ear very much until last summer, when he 
had a sore throat and dyspepsia, when his attention was again called to his ears. 
He then observed a drumming noise in the left ear, and some impairment of 
hearing. The hearing distance was found to be E., JJi; L., ? f~-. The tuning- 
fork was heard better in the worse ear. The pharynx was granular. The right 
drum-head was very much sunken, and there were opacities in it. The light 
spot was of good size. The left membrana tympani was covered by hard wax. 
When it was removed the drum-head was found to be sunken, and it had no 
light spot. On removal of the cerumen, the hearing distance arose from ^ to 
-/«, and after inflation to ^. 

The history and examination show that this was a case of 
disease of the middle ear. It is probable that the hearing power 
'was only slightly impaired, until the attack of inspissated ceru- 
men, which reduced it so much as to call the patient's attention 
to it. From my data, I believe that the average hearing power 
of the side affected by the parotitis was ££. 

Case VI. — Double Parotitis followed by Absolute Deafness — Patient seen TJiirty- 

tico Days after occurrence of Deafness. — February 26, 1875, Mabel O , aged 

four and a half. The patient had parotitis about thirty-two days ago. She 
recovered promptly. Five days after began to suffer from impairment of hearing, 
and in twenty-four hours she became deaf. For two or three days there was 



DEAFNESS FROM PAROTITIS. 637 

some unsteadiness in her walk, also occasional vomiting. The little patient 
was very weak. 

The patient was found to be absolutely deaf. The drum-heads were normal 
in appearance. No improvement resulted from treatment. That this was a case 
of disease of the labyrinth is indisputable. 

Case VII. — Sudden Deafness of One Ear after Mumps — Patient seen a Year 
after the Disease occurred. — May 3, 1880, E. W. H , of Australia, aged twenty- 
three. The patient states, that he became deaf rather suddenly in the left 
ear, after an attack of mumps about a year ago. He also had a low fever. Just 
as he was recovering from the mumps, he found that he was hard of hearing on 
the left side. He could hear the ticking of a watch however. He has remained 
hard of hearing from that time. H. D., R., ff ; L., - 4 %. The bone conduction for 
tuning-fork is better than aerial on the left side. Both membranse tympani 
are opaque. No improvement to the hearing resulted from inflation. 

This is, I think, a clear case of disease of the middle ear after 
parotitis ; that the internal ear may also have been affected, 
will not be denied. Yet the probabilities are, that the disease 
was situated exclusively in the middle ear. The tuning-fork 
test is, I think, very reliable in determining the situation of the 
lesion, and that certainly positively indicated disease of the 
middle ear. 

Case VIII. — Parotitis Three Weeks before — Deafness Two Weeks since — Dizzi- 
ness for One Week — Dulness of Hearing in the Right Ear also, which soon passed 

away — Constant Tinnitus. — June 25, 1881, W. D. C , aged forty-one, sent 

to me by Dr. J. W. S. Gouley. 

H. D., R, \l', L., /o (?). The tuning-fork is heard only in the right ear. It 
is not heard at all by aerial conduction on the left side. 

As I said, in discussing this case in the Archives, although 
it had become one of the labyrinth on the left side, it may have 
begun in the middle ear, for on the other side there was a slight 
affection of the middle ear, which passed away. I see no reason 
why a slight affection of the middle ear may not have extended 
and become a serious affection in a part that tolerates only a 
very slight lesion ; certainly the labyrinth is in direct communi- 
cation by blood-vessels with the tympanic cavity, which, in 
turn, through the auditory canal and the mastoid process is 
directly connected with the parotid gland. 

Case IX — Parotitis a Year before Patient was seen by the Writer — Hearing 

was found to be Impaired soon after. — March 11, 1882, Janet R , aged twelve, 

sent to me by Dr. J. W. S. Gouley. The patient had parotitis on both sides 
a year ago. She make a slow recovery. Her hearing was found to be impaired 
soon after, and it has remained so. Her general health is fair. 

H. D.: R., \% ; L., 4 2 . She cannot say in which ear the vibrating tuning-fork 



638 DEAFNESS FROM PAROTITIS. 

is heard, when placed upon the forehead or teeth. In the left or bad ear the 
bone conduction is better than the aerial. 

The drum-heads are slightly sunken and the light spots are small. The 
hearing is diminished immediately after inflation. 

The patient was seen a few times, but as she seemed to be rather worse for 
treatment of the middle ear, she was dismissed unimproved. 

This case seems to me to be a clear one of disease of the 
middle ear, although I will not undertake to say that there was 
not also a lesion of the labyrinth. The fact that she invariably 
became worse after inflation of the ear inclines me to think so. 
But the fact that there was still considerable hearing power left 
in the ear, inclines me to the belief that the affection was pri- 
marily in the middle ear. 

Case X. — Parotitis on Each Side — drill Fourth or Fifth Day after — Great Im- 
pairment of Hearing — Recovery of One Side after Inflation of the Middle Ears — 

Improvement m the Other. — Robert B , aged eight, was brought to me by his 

mother on April 24, 1882, with the following history : About three weeks before 
he was attacked with mumps, affecting each side. On the fourth or fifth day 
after the mumps appeared, he had chilly sensations one evening, probably in 
consequence of the lowering of the temperature of the room in which he was. 
The next day he had a high fever ; he vomited ; and on that day it was observed 
that he did not hear well. His hearing has not become worse since, perhaps he 
is slightly better. He was treated by his attending physician by being kept 
warm, and injections of a warm solution of chlorate of potash were daily made 
to his throat. He did not improve much, however. On examination it is 
found that he hears loud conversation four feet behind his back. Watch : 
■r L . t % 

The tuning-fork is heard much better through the bones than through the 
air, on each side. 

The right membrana tympani is of good color. There is a well-formed light 
spot, and it is not sunken. In the left membrana the light spot is small. 

On inflation of the middle ear by Politzer's method, the hearing distance for 
the watch becomes t» on the right side and is on the left, while the voice is 
now heard 30 feet. 

The patient remained under observation until June. He was treated by the 
use of Politzer's method of inflation, by syringing tl ' uaso-pharyngeal space 
with a solution of chlorate of potash ; and he took cod-liver oil. He then went 
abroad with his parents. He was directed to continue the treatment, according 
to circumstances, during the summer. When he returned in October, he could 
hear general conversation with ease, but on the right side the watch was only 
heard when laid upon the ear, and on the left side for 8 inches. E., -^ ; L., ■£$. 
Voice, 30'. About a month afterward, while under treatment, after the escape 
of quite an amount of dark-colored viscid material from his nostrils, the patient 
said that sounds were unusually loud. On examination the next day it was 
found that the hearing distance of the right ear was - 4 % , and the left f£. After 
inflation the hearing distance of the left ear became normal, while the right re- 
mained unchanged. At the present time the patient has passed through an 



DEAFNESS FROM PAROTITIS. 639 

attack of inflammation of the auditory canal and tympanic cavity from exposure 
to cold, but his hearing has become normal on the left side, while it remains 
impaired on the right. 

February 9th. — E., \$; L., ff. Voice on right side, with normal ear closed, 
20 feet. The patient is still under treatment. 

This case of impairment of hearing after mumps is a very 
plain one. It is undoubtedly a case of disease of the middle ear 
and not of the nerve. The tuning-fork and the results of treat- 
ment indicate this. Yet he had symptoms that are sometimes 
associated with an affection of the labyrinth. It is quite pos- 
sible that such an affection might have occurred in the course 
of any acute disease, if the patient were exposed to a chilling 
of the body. I am confident, however, that if all the cases of 
impaired hearing occurring after mumps were observed by an 
otologist as early as this one v/as, that a similar process would 
sometimes be found. Most of the cases seen by an aurist are 
only seen some time after their occurrence, when the history 
is very vague. The chief symptom is said to be sudden deaf- 
ness. In this case the deafness was sudden. Had not infla- 
tion come to its relief, within a few weeks, this might have 
been called a metastatic case ; and I believe the labyrinth 
might have been invaded by the extension of the inflamma- 
tory process through the fenestrse. I see no reason as yet tc 
change the opinion expressed in this book, 1 and in my article, 
from which I have quoted, that in some cases the occurrence 
of inflammation of the ear after mumps is by direct exten- 
sion of the inflammation to the auditory canal, middle ear, 
and labyrinth. That there may be a form of so-called meta- 
static inflammation, I do not deny. Whether the channel of 
communication is through the blood, cannot as yet be deter- 
mined. To my mind the probabilities lie in that direction. The 
theory of a metastatic inflammation in these cases is usually 
not based upon the study of the symptoms at the time they oc- 
curred, but upon reasoning from analogy : for example, it is said, 
because the testes and breasts are sometimes affected by metas- 
tatic inflammation, therefore a disease of the ear. occurring 
after mumps, is also a metastatic affection. Hinton, as is seen 
by the quotation, thought a catarrhal inflammation of the mid- 
dle ear one of the causes, in some cases at least, of the impair- 
ment of hearing often seen after mumps. As I have shown, my 
last case was certainly of this character. 

Every one admits that cases of extension of suppurative in- 
flammation of the parotid gland to the external auditory canal, 

1 Fourth edition, 1878, p. 530. 



640 DEAFNESS FROM PAEOTITIS. 

are not uncommon. Probably this extension may take place 
through the fissures of Santorini. If a suppuration may extend 
in this way, why not a catarrhal process ? We are not without 
examples of the extension of an inflammation to the middle ear 
from the auditory canal and outer layer of the drum-head. 
Every physician at all accustomed to see much of aural disease, 
has seen cases where from a draught of cold air, the entrance of 
cold water or irritating substances, an inflammation has been 
set up in the middle ear by extension, and where the symptoms 
in the auditory canal have passed away long before those in the 
middle ear have been relieved. 

As a result of my observations I conclude — 

1. An acute catarrh of the middle ear may occur during the 
course of mumps, and be attended by fever and vomiting. 

2. This catarrh may extend from the parotid gland, through 
the auditory canal and outer layer of the drum-head, or through 
the mastoid process. 

3. An affection of the labyrinth may occur simultaneously, 
or by extension from the middle ear. 

4. It is probable that there are cases where the disease during 
the course of mumps, is transferred to the labyrinth, in the same 
manner that an inflammation sometimes occurs in the testes 
and the breasts, but this cannot be considered as proven, until 
more detailed experience is furnished of cases observed a few 
hours after the impairment of hearing occurs. 

Noyes showed an interesting case of deafness after mumps 
at the New York Ophthalmological Society. It occurred in an 
adult. The loss of hearing was accompanied by a staggering 
gait. Only one ear was affected, and on this side there was also 
metastatic orchitis. 

ACUTE INFLAMMATION OF THE MEMBRANOUS LABYRINTH MISTAKEN 
FOR CEREBRO-SPINAL MENINGITIS. 

As has already been said, Voltolini ' was the first writer to 
call attention to the subject. The discussion which his views 
have excited has been at times a heated one, but it has done 
great good in calling the attention of general practitioners to the 
possibility of mistaking a disease of the ear for one of the brain 
or medulla. 

The symptoms of epidemic cerebro-spinal meningitis, as given 
by Clymer, 2 are " great prostration of the vital powers, severe 

1 Monatsschrift fur Ohrenheilkunde, Jahrgang L, No. 1. 

2 Reprint from the American edition of Aitken's Science and Practice of Medicine, 

1872. 



ACUTE INFLAMMATION OF MEMBRANOUS LABYRINTH. 641 

pain in the head and along the spinal column, delirium, tetanic 
and occasionally clonic spasm, and cutaneous hyperesthesia, 
with, in some cases, stupor, coma, and motor paralysis, attended 
frequently with cutaneous hsemic spots." Dr. Clymer's definition 
is so comprehensive and guarded that it would be difficult to say 
that the symptoms of labyrinth-disease, as given by Voltolini, 
may not accord with those of cerebro-spinal meningitis. I am 
inclined to think that Dr. Clymer has made his definition very 
comprehensive, in order to take in the sporadic cases. Volto- 
lini regards these as affections of the labyrinth. Voltolini says, 1 
"The children are attacked quite suddenly, and without appar- 
ent cause ; consciousness is soon lost as a rule, but the head is 
frequently grasped with the hands. There is severe fever, a 
fixed countenance. They bury the head in the pillow. There 
are sometimes slight symptoms of paralysis, but they are never 
permanent ; occasionally there is vomiting. Sometimes the dis- 
ease has something of an intermittent character. The cerebral 
symptoms soon disappear, but the patient is found to be per- 
fectly deaf, and walks with a staggering gait." 

Voltolini lays particular stress upon the absence of facial par- 
alysis in these supposed cases of cerebro-spinal meningitis, and 
he asks, how is it possible to have an exudation in the medulla 
oblongata, at the origin of the auditory nerve, without having 
at the same time one of the facial, when the fibres of the two 
nerves are so near each other ? Knapp cannot agree with Vol- 
tolini in his idea of primary inflammation of the membranous 
labyrinth, and has discussed the subject quite fully in a "Clini- 
cal Analysis of Inflammatory Affections of the Middle Ear." 2 
Knapp's argument against Voltolini's view is embraced in the 
following question: "If the same complex symptoms in some 
cases produce deafness, in others blindness, and in many others 
neither, why should we call the first group otitis labyrinthica, 
mistaken for meningitis, while in the second group the depen- 
dence of the ocular affection on the cerebro-spinal disease may 
be demonstrated?" It is no answer to Voltolini's arguments, 
to say, as has been said, that cases of inflammation of the mem- 
branous labyrinth are ," abortive" cases of cerebro-spinal menin- 
gitis. Voltolini went too far in thinking that there was no such 
disease causing deafness, as cerebro-spinal meningitis : but be- 
cause so-called "spotted fever "does exist, and transmits dis- 
ease to the auditory and optic nerves, this fact furnishes no 
evidence that primary affections of the nerve-trunks, or of their 

1 Monatssclirift fur Ohrenheilkunde, loe. cit 

2 Archives of Ophthalmology and Otology, vol. ii., No. 1. 
41 



642 ACUTE INFLAMMATION OF LABYRINTH. 

expansions, may not occur, just as we may have primary optic 
neuritis. But here, also, gaps in our knowledge are to be filled, 
a task that must be performed by the post-mortem examinations 
made by the practitioners of the present or future. 

Case I. — Severe Headache and Vomiting — Partial Delirium — Deafnessinafew 
Bays — No Paralysis — Recovery from all Symptoms but Deafness. — May 3, 1873. 

Sally A , aged thirteen. Three months ago this child was attacked with 

vomiting and pains in the head. She became only slightly delirious. There was 
no paralysis of any kind. The hearing was found to be impaired in a very few 
days, and she became deaf soon, and has remained so. She was taken sick on 
Saturday, and on Wednesday she heard as badly as now. She is now perfectly 
deaf, but concussions hurt her ears. She walks with difficulty, that is, the gait 
is staggering. 

Case H. — Convulsions — Deafness. — March 25, 1872. Martha , aged 

eleven, when sixteen months old, had some kind of convulsions, and since has 
been deaf. Had spoken words and given other evidences of hearing before 
this. She never had any disease of the head, nor discharge from the ear. She 
cannot now hear the ticking of a watch, nor words spoken into the ear ; but the 
vibrations of a tuning-fork are plainly perceived. Both membranse tympani 
are sunken. 

Case III. — Inflammation of Labyrinth from Cold, induced by lying down while 

in a State of Perspiration. — June 9, 1873. George O'B , aged thirty-one. agent, 

one day last summer lay down while in a state of profuse perspiration. The next 
day he observed a singing noise in his right ear, and that then he did not hear 
well on that side. There were also darting pains across his head and the back 
of the auricle. Is anxious and worried. States that he had an acute inflamma- 
tion of the head some time since. Hearing distance : right ear, ; left, ||. The 
membranse tympani show no signs of disease. The tuning-fork is heard most 
distinctly on the left side. 

Case IV. — Pain — Paralysis — Deafness. — Maria L , aged three, when two 

years and a month old, awoke one night screaming with pain. She did not roll 
her head, or become unconscious, but lost power over her limbs, and had general 
febrile excitement. She was ill for one week, but it was two months before she 
could walk. On recovery, she was found to be deaf, and is now almost, if not en- 
tirely, devoid of hearing. The membranas tympani of each side altered in cur- 
vature and color. 

The practitioner will judge for himself as to how much in- 
flammation of the spinal cord, or membranes of the brain, there 
is in such cases as these. 



HEMORRHAGES AND EFFUSIONS. 

I think we have a right to conclude, from the clinical history 
of certain cases, that a hemorrhage or effusion of serum into 
the membranous labyrinth may occur without any well-defined 
cause. Of course, in atheromatous degeneration of other blood- 



HEMORRHAGES. 643 

vessels of the body, we may also suppose that such a hemor- 
rhage sometimes occurs. The following case is a fair type of 
what is meant by hemorrhage or effusion into the labyrinth : 

Profound Deafness of Both Ears, accompanied by Vomiting, and Loss of Equilib- 
rium, occurring in One Night. — A healthy young man aged twenty-two consulted 
me at the instance of Dr. Howard Pinkney, and gave the following history : 
His occupation was that of a wagoner. He was attacked one night with vomit- 
ing and dizziness, and in a few hours he found himself completely deaf in both 
ears. He could not hear the loudest sounds. The nausea and dizziness con- 
tinued for about two weeks. He was so weakened that he could not get out of 
bed, but he retained his intellect and consciousness, and he stated that there 
was no paralysis of any part of his body ; he could lift his head, his arms, move 
his legs, and all parts of his body. There were no cases of cerebro-spinal men- 
ingitis in the place where this attack occurred. He had had a suppuration in 
the right ear some years before, and could not hear well from that ear before 
this attack. It is now three months since his deafness came on, and he is no 
better. The patient is ruddy and in vigorous health ; there is no cardiac or 
renal disease. He has not had syphilis. He walks with a staggering gait. His 
intellect is unclouded. He has tinnitus annum, which he compares to the 
chirping of crickets. The vision is good. He is still dizzy at times. An ob- 
jective examination showed evidences of old inflammation in the right membrana 
tympani, but there was no inflammatory action going on. The membrane was 
transparent, except on the posterior and inferior quadrant, where it was sunken 
and adherent to the wall of the tympanic cavity. The left membrana tympani 
was normal. He did not hear the watch at all, nor words spoken through a tube 
placed in the external meatus. Air enters both Eustachian tubes. The tuning- 
fork was not heard better when the ears were stopped. 

I think there is no reasonable doubt that this was a case of 
hemorrhage into the semi-circular canals and the cochlea. I 
have seen several such, and some where no vomiting occurred, 
but sudden deafness with absolutely no premonition. We are 
still in need, however, of post-mortem investigations to establish 
our theories founded on clinical experience. Inasmuch as such 
patients do not usually die of disease of the labyrinth, we have 
not the same facilities for clearing up a diagnosis that we 
have in fatal affections. 



INJURIES OF THE OSSEOUS LABYRINTH. 

In the chapter upon fractures of the temporal bone, it was 
seen that there were such injuries which involve the tympanum 
only, but there are also cases in which both the osseous and mem- 
branous labyrinth are injured, and absolute deafness results. 

Case I. — Severe, Fall — Complete Deafness on One Side — Normal Drum U 
branes. — September 14, 18(55. E. M , aged eleven, live years ago, oar when six 



644 concussions. 

rears old, had a severe fall down stairs, striking his head, and he has been totally 
deaf on the right side ever since. The drum-heads of both sides are normal. He 
cannot hear the ticking of the watch on the right side, except when upon the 
mastoid region, the meatus being closed. The air is easily forced through both 
tubes by Politzer's method and by the exrjeriinent of Valsalva, but no improve- 
ment to the hearing results. 

Case II. — Profound Deafness from Blows on the Head. — St. Vincent's Hos- 
pital, January 6, 1868, a patient under the care of Dr. J. L. Little. This man, 
aged forty-five, ^as severely beaten in a fight some few months since ; he was 
unconscious for four days, and. when restored to consciousness, was perfectly 
deaf, in which condition he sail remains. His gait is irregular ; he finds great 
difficulty in keeping his head in an erect position, even when supporting it with 
his hand. Marks of blows are still traceable over one eye and the right mastoid 
process. There seems to be an entire absence of hearing power, as found by all 
the tests capable of application. He seems very much dejected, but is well 
nourished. Both membranaB tympani, especially the left, appear sunken, and 
have lost their transparency. Air enters both ears by Politzer's method ; the 
pharynx is in fair condition. 

I think we may fairly conclude, in this case, that the blows 
produced an inflammatory action in the nerve, as well as in the 
meninges of the brain and the parts of the middle ear. and this 
is probably the ultimate lesion in the case of blows and falls. 
The blood-vessels are perhaps at first ruptured : and we know. 
from post-mortems in similar cases, that suppurative inflamma- 
tion of the labyrinth and basilar meningitis have resulted. In 
ophthalmic practice we observe cases in which atrophy of the 
optic nerve follows severe injuries upon the side of the head ; 
but this atrophy sometimes presents no ophthalmoscopic appear- 
ances at first — or at least very few. and may affect but one nerve. 
In other cases, hyperemia or inflammation precede the atrophy. 



CONCUSSIONS OF THE LABYRINTH (BOILERMAKERS" DEAFNESS). 

Workmen employed in hammering large iron plates, such as 
are used in making the boilers of large steam-engines, are very 
apt to lose much of their hearing power. So many of these 
cases are seen at ear infirmaries, that at one time " Boiler- 
makers' Deafness ? ' figured as a separate disease of the ear in 
the statistical reports of one of our institutions where aural dis- 
ease was treated. Examination of such cases has shown me 
that the lesion causing the impairment of hearing and deafness 
must be sought for in the labyrinth, and that it is probably due 
to concussion of the fibres of the nerve in the cochlea and semi- 
circular canals. 

Concussions of the labyrinth, from cannonading, such as are 



DEAFNESS. 645 

sometimes experienced by soldiers and sailors, the impaired 
hearing" and extreme sensitiveness of the ears sometimes ob- 
served in telegraph operators, belong to this class of labyrinth 
affections. 

There can be no hesitancy in believing that the continual 
recurrence of a kind of sound, that has no musical, but, on the 
contrary, an unpleasant character, must at last cause a hyperse- 
mia of the ultimate nerve-fibres of the cochlea. The incessant 
shock of the drum-head by the blows from dozens or even hun- 
dreds of hammers upon vibrating plates must agitate these 
fibres in such a manner as to finally put them out of tune, as 
certainly as the constant use of a piano will at last loosen its 
strings. Clinical experience confirms this view, and my own 
observations and investigations in reference to boiler-makers' 
shops seem to demonstrate the following facts : 

I. Boiler-makers are nearly all hard of hearing. 

II. The impairment of hearing is generally attributable to 
some lesion of the labyrinth, probably of the cochlea. 

Superadded to this serious trouble, tympanic or middle ear 
catarrh or impacted wax are very frequently present, but these 
must be regarded as purely coincidental. Boiler-makers are con- 
stantly exposed to sudden and marked changes of temperature, 
and hence often catch cold, intensifying and increasing by this 
means the aural affection. 

Should a man, already suffering from disease of the middle 
ear, begin to work in a boiler-shop, he will, of course, suffer in 
a much greater degree, and the organ be more susceptible of 
additional injury, than a man who is in the enjoyment of a 
sound organ of hearing. Dr. D. R. Ambrose has shown me a 
case which confirms this view. In the same way, a telegraph 
operator who has pharyngeal catarrh, and consequently a 
swelled Eustachian tube, which is not always capable of per- 
forming its proper function, will be more sensitive to, and suffer 
more acutely from, the concussions of the instrument, than he 
who has a healthy throat. The existence of tympanic and tubal 
catarrh will cause the Eustachian passage to be less pervious, 
or even at times entirely closed ; and thus aggravate the un- 
pleasant conditions existing when waves of sound that have to 
go but a short distance, and are besides inclosed in tubes, and 
thus increased in intensity, impinge upon the molecules that 
make up the ultimate fibres of the auditory nerve. 

Those who work inside the boilers as riveters, and who thus 
have shorter waves of sound striking upon their ears, lose their 
hearing power most completely, as is evidenced by the testi- 
mony of all old boiler-makers. It is not easy, in the absence 



646 boiler-makers' deaeness. 

of post-mortem investigations, to define the exact nature of the 
lesion, but it may be a passive congestion of the contents of the 
cochlea. 

Boiler-makers speak in graphic language of the effects of the 
din upon their ears. Said one of them tome: " Those heavy 
hammers jar every nerve in the body." They do not find much 
relief from wearing cotton in their ears, except when first enter- 
ing the shop. An experienced workman, however, told me that 
all old boiler-makers had learned to equalize the pressure and 
reduce the shock by opening the mouth frequently. Of course, 
by this procedure they open the Eustachian tube more freely. 

My reasons for believing that the lesion in these cases is 
situated in the nerve predominantly, are that the aerial conduc- 
tion is always louder than the bone conduction, as tested by 
the tuning-fork "C 2 ," and that it is heard longer than by bone 
conduction. The only apparent exceptions to this rule were 
those in which, in addition to the lesion of the acoustic nerve, 
there was also inspissated cerumen. When the wax was re- 
moved, however, and the cases were transposed into their proper 
place, of diseases of the acoustic nerve produced by concussion, 
the tuning-fork was heard through the air louder and longer 
than through the bone. I consider all the other tests that we as 
yet have, for the differential diagnosis of affections of the mid- 
dle and internal ear, as so much inferior to this, although of 
great corroborative value, that I am constrained to consider all 
observations upon boiler-makers that have not been made in 
this way, as so defective as to tell nothing of the true seat of 
the disease. In addition to the test by the tuning-fork, the ex- 
amination of the hearing power by the voice shows that these 
patients hear better in a quiet place than in a noise. As has 
been suggested by many writers, there is no doubt that some- 
thing might be done to avert the consequences of those concus- 
sions in producing disease of the acoustic nerve, if workmen 
could be induced to wear ear protectors ; but from some reason or 
other, they are, as a rule, quite averse to wearing cotton in their 
ears, or any contrivance for protecting their ears from the effect 
of a great and constant concussion. Almost all boiler-makers 
say that they were deafer at first than after they had become 
accustomed to the occupation ; and they all say that they hear 
better after a period of rest, for example from Saturday to Mon- 
day. 

That excessive sound must necessarily be as harmful to the 
nerve of hearing, as is excessive light to that of sight, is a 
natural deduction from our knowledge of the effects of the 
waves that produce those two senses, and all experience con- 



BOILER-MA KEKS' DEAFNESS. 647 

firms the belief that there may be an acoustic neuritis produced 
by noise, as well as an optic neuritis caused by exposure to a 
glare. 

The cases upon which my conclusions as to boiler-makers' 
deafness depend are as follows : l 

Case I. — Boiler-maker Twenty Years — Disease of the Acoustic Nerve. — John 

F , aged thirty-five. Has been in the business for twenty years. Hearing 

was good when he began ; began hearing noises in his ears ; then became hard 
of hearing gradually. Cannot now hear a lecture. Does not hear better in the 
noise of the shops, but he assists his ears by watching the lips of those speaking 
to him. Was most deaf after working in a boiler. Did not use cotton, because 
it made him worse when removed. Hissing tinnitus all the time. Hearing : E., 
4 P 8 , aerial conduction best ; air duration, 23 seconds ; bone, 11 seconds. L., ^\, 
aerial conduction best ; air duration, 20 seconds ; bone, 9 seconds. M. T. : E., 
good color, good light spot, not sunken ; L., sunken, two light spots, good color. 
Says that he has never had catarrh. 

Case II. — Boiler-maker Thirty Years — Disease of Acoustic Nerve. — X. Y , 

forty-six years of age. Has been in the business for thirty years. Hearing was 
good when he began his work. Now cannot hear well when spoken to. Thinks 
he hears better in a noise, because people speak louder. No pain at any time, 
but has noises, and hearing failed gradually. Has used cotton, but does not 
like it. Hearing: E., ~, aerial conduction best; watch not heard on mastoid ; 
aerial conduction, 26 seconds ; bone, 12 seconds. L., ~, aerial conduction best ; 
watch not heard on mastoid ; aerial conduction, 21 seconds ; bone, 8 seconds. 
M. T. : E., opaque, no light spot, vascular along handle of the malleus; L., 
opaque, sunken, no light spot. Pharynx sound. 

Case III. — Boiler-maker Twenty-four Years — Disease of Nerve — One Side of 
the Middle Ear and Nerve on the Other. — Forty-seven years of age. Has been in 
the business twenty-four years. Hearing was good before he began it. Sissing 
tinnitus. Deafness came on gradually, but was worse when he was "holdnig 
on"; no pain. Cotton did no good. Hearing: E., &-, aerial, but no bone con- 
duction ; duration of aerial conduction, 6 seconds; bone, 0. L., iV, aerial, feels 
something ; bone conduction distinct ; duration of aerial conduction, ; bone, 
12. M. T. : E., opaque rim, vascular malleus, no light spot; L., good color, 
vascular malleus, no light spot. Pharynx catarrhal ; uvula elongated. 

Case IV. — Boiler-maker Twenty-four Years — Disease of Acoustic Nerves. — 
Fifty-one years of age. Has been in the business twenty-four years ; previous 
to which his hearing was very sharp, now is very poor. Sissing tinnitus ; does 
not hear any better in the shop or car. Wears cotton at times. No pain in ear. 
Health good. Voice at four feet. Hearing: E., ^, aerial feeble; no bone 
conduction ; aerial duration, 5 seconds ; bone, 0. L., T p ^, aerial feeble ; no bone 
conduction ; aerial duration, 6 seconds ; bone, 0. M. T. : E., opaque (wax) ; 
L., opaque on periphery, no light spot. Pharynx in good condition. 



1 Reprinted from Archives of Otology, vol. xii., p. 111. 



648 BOILER-MAKEKS' DEAFNESS. 

Case V. — Boiler-maker Twelve Years — Disease of Acoustic Nerve. — Aged 
twenty-five. Has been in the business twelve years. Hearing is good ; no pain 
or noises. Hearing : E., &, aerial best ; aerial duration, 21 seconds ; bone, 7 
seconds. L., Vf, aerial best ; aerial duration, 20 seconds ; bone, 10 seconds. 
M. T. : E., good light spot, opaque on periphery and above ; L., good light 
spot, opaque. Catarrhal pharynx. 

Case VI. — Assistant in Boiler-shop for One and a Half Year. — Works ten 
hours per day. Thinks his hearing is good enough. Hears ordinary conversa- 
tion with his face away from the speaker about twenty feet. Hearing : E. E., 
aerial conduction louder; air duration, 10 seconds; bone, 5 seconds. L., i|, 
aerial conduction louder ; air duration, 16 seconds ; bone, 4 seconds. M. T. : 
E., small light spot, opaque; L., small light spot, vascular. Pharynx healthy. 

Case VII. — Boiler-maker Thirteen Years — Disease of Middle and Internal 
Ears. — Has been in the business thirteen years. Hearing always good. Never 
protected his ears. Had a pain in left ear once, but no discharge. Whispers 
heard by others not heard by him. Does not hear better in noise. Hearing : 
E., ~^, bone conduction best ; aerial duration, 10 seconds ; bone, 9 seconds. 
L., -~, bone conduction best ; aerial duration, 13 seconds ; bone, 7 seconds. 
M. T. : E., good color and light spot; L., sunken, opaque, small light spot. 
Tonsil enlarged. Pharyngitis. 

Case VIII. — Aged Eighteen — Boiler-maker for Fifteen Months — Disease of 
Acoustic Nerve. — Has been in business fifteen months. Hearing good when he 
came. Not so good now. Hissing tinnitus. No pain. Does not hear better 
in noise. Hearing: E., - 4 - 8 -, aerial best; aerial duration, 12 seconds; bone, 9 
seconds. L., if, aerial best ; aerial duration, 14 seconds; bone, 7 seconds. M. 
T. : E., small light spot, prominent short process; L., no light spot, prominent 
short process Slight pharyngitis. 

Case IX. — Thirty Years a Boiler-maker — Inspissated Cerumen — Disease of 
Acoustic Nerve. — Aged forty-nine. This subject is what is technically called a 
"holder-on." His duties keep him inside of the boiler holding on to the rivets. 
The shock of sound is much greater here than in the open air of the shop. 
Thirty years a boiler-maker. Three and a half years in navy. Ears were good 
when he went into the present business. Hears better when he gets away from 
noise. Voice, 6'. Watch, -&, each side. Tuning-fork: E. E., aerial louder, 8 ; 
bone louder, 3. L. E., aerial louder, 8 ; bone louder, 4. Inspissated cerumen 
on each side. After removal of large plugs of very hard wax, H. D. for the voice 
increased to 18 ', and the watch was heard, when pressed on each side, /,. The 
duration of the aerial conduction was increased, but no change in the intensity 
with which it was heard. 

It is interesting to note in this case that the aerial conduc- 
tion was louder and longer, even when the ear was plugged 
with wax. This shows a more marked lesion of the nerve, than 
the other cases in which inspissated cerumen was found — for in 



BOILER-MAKERS' DEAFNESS. 649 

these latter the bone conduction was better until the wax was 
removed, when the aerial conduction was found to be as is usual 
in those suffering from boiler-makers' deafness. 



Case X. — Boiler-maker Thirty-one Tears — Disease of Acoustic Nerve. — James 

L , forty-seven. Boiler-maker thirty-one years. First job was that of 

riveter, and in twenty days could not hear well ; tinnitus like bees ; never had 
earache; healthy; rheumatism; voice 20'. Hearing: E., - 4 & 8 - ; L.. 4 5 ,-, aerial 
conduction better each side ; R., aerial, 12 seconds ; bone, 8 seconds ; L., aerial, 
9 seconds; bone, 9 seconds. M. T. : R., good light spot, good lobe; L., good 
light spot, good lobe. Both opaque on periphery. Healthy pharynx. 

Case XI. — Boiler-maker for Twenty Years — Inspissated Cerumen removed from 
Both Sides — Disease of Acoustic Nerves. — Aged thirty-nine. Has been twenty 
years in the business. Ears were sound when he began ; had an occasional 
earache as a boy. He can't hear a whisper ; does not hear well in a boiler-shop. 
Watches the mouth and gestures. Hears the voice in a quiet room 40 ' . Watch : 
R., - 4 - 8 -; L., - 4 %. R. side the aerial conduction is better ; on the left the bone con- 
duction is better. B., aerial conduction is heard 12 seconds; bone, 6 seconds. 
L., aerial conduction is heard 12 seconds; bone, 8 seconds. Pharynx is sound. 
Inspissated cerumen is found on each side. After it is removed the watch is 
heard better on each side ; e.g., R., /g ; L., / 8 -. Relative distinctness of bone 
and aerial conduction not changed. Duration of the sound about as before. 



Case XII. — Boiler-maker Twenty-jive Years — Inspissated Cerumen Both Sides 
— Disease of Acoustic Nerves. — Aged forty-three. This man has been a boiler- 
maker twenty-five years. He had good hearing when he began his work. 
Never had an earache. Hears the voice in a quiet room 30 '. Watch ~ "|- on 
right side, -{\ on left side. R. side, bone conduction much more distinct ; L. side, 
the same. Duration : R , aerial conduction, 5 seconds ; bone, 12 seconds ; left 
side, aerial, 14 seconds ; bone, 11 seconds. Inspissated cerumen, each side, re- 
moved. After removal of wax watch was heard - 4 3 (T and -fo on the right and left 
sides respectively, instead of ~ and JL, TJie aerial conduction became better in 
each ear. Duration as follows: R., aerial, 18 seconds; bone, 13 seconds; L., 
aerial, 22 seconds ; bone, 12 seconds. 

As is seen, the peripheric trouble (inspissated cerumen) 
masked the disease of the acoustic nerve in this case, but when 
the wax was removed the lesion of a boiler-maker's ear was 
found to exist. 

In Case VII. the bone conduction was decidedly louder than 
the aerial, but the tuning-fork was heard much longer through 
the air than through the bone. The left drum-head was sunken 
and opaque, and there was considerable throat trouble. From 
these data I conclude that there is disease of the middle as well 
as of the internal ear in that case. 



650 



BOILEE-MAKEES' DEAFNESS. 



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651 

From all the observations I have been able to make upon this 
subject, I think I am justifiable in drawing the following con- 
clusions : 

1. The hearing power of persons working in such a din as 
that of a boiler-shop invariably becomes impaired. 

2. The lesion caused by this occupation is one of the mem- 
branous labyrinth, or of the trunk of the acoustic nerve. 

3. Persons thus affected do not hear better in a noise. Their 
hearing power is better in a quiet place, and becomes better 
after prolonged absence from the exciting cause of their im- 
paired hearing. 

4. The cases of inspissated cerumen, catarrh of the middle 
ear, occurring among boiler-makers, are such as occur among 
those employed in various occupations and only mask and com- 
plicate the fundamental primary trouble, so long known as 
boiler-makers' deafness. 

For an account of my first examination of the hearing of boiler-makers, the 
reader is referred to my work on the "Ear," edition of 1877, and to the Ameri- 
can Journal of the Medical Sciences, 1874, vol., lxviii,, p. 380. 

Other occupations of a similar nature, that is, occupations 
amid continuous concussions, undoubtedly cause the same le- 
sion. A recent visit to an establishment where two engineers 
were employed for the production of electric light, showed me 
that they had become somewhat hard of hearing, since they 
had been engaged in an occupation exposing them to the sound 
of regular concussions from the striking of metallic plates to- 
gether. 



CASES OF TINNITUS AURIUM AND IMPAIRMENT OF HEARING FROM 
OTHER KINDS OF CONCUSSIONS. 

Case I. — Tinnitus Aurium, without Impairment of Hearing, occurring from 
Listening to a Telegraph Instrument — Hypercemia of Acoustic Nerve? — W. G. 

B , aged thirty-seven, states that he has been a telegraph operator for about 

twenty years, and that he has had tinnitus annum for about two years. Hear- 
ing distance: right, ||; left, fg. Both membrane tympani have good light 
spots ; there is some granular pharyngitis. The patient is confident that the 
vibrations of the telegraphic instrument have caused the noise in his ears. The 
sound of the instrument is very unpleasant to him, and he is obliged to protect 
his ears, while at work, by cotton plugs. Indeed, his ears have got into such a 
sensitive condition that jarring sounds of any kind are extremely annoying to 
him. The patient is in good general health. 

Case II. — Impairment of Hearing of One Side, ascribed to Occupation as 7" 
graph Operator. — May 4, 1870. Mr. B , aged twenty-seven, about a year ago 



652 CONCUSSIONS OF ACOUSTIC NERVE. 

discovered that the hearing power of his left ear was somewhat impaired. Three 
months ago he was troubled with a continuous noise in that part of his head. 
He is a telegraph operator, and has been accustomed to use his left ear — leaning 
his head over the machine on that side and intently listening. He believer 
that this is the cause of his loss of hearing. The drum-heads look very much 
alike, both exhibiting peripheral opacities, but in other respects having a normal 
appearance. The pharynx and nares seem to be healthy. Inflation of the ears 
has no effect upon the hearing. The watch is not heard at all on the affected 
side, nor is the tuning-fork. 

Case III. — Exposure to Cannonading — Tinnitus — Impairment of Hearing for 

the Watch, out not for Ordinary Conversation. — February 11, 1868. W. R. X , 

aged twenty-five, observed some difficulty in hearing ten years ago ; and, after 
being exposed on a gunboat to severe cannonading, while an officer in the navy, 
he became worse, although he has scarcely any tinnitus aurium. Hearing dis- 
tance : right ear, ~h ', left ear, -£*. Both drum-heads appear to be normal. Air 
enters each Eustachian tube freely, but inflation causes no improvement in the 
hearing power. 

I have had ample opportunity to test the hearing power of 
this patient in conversation, which he hears so well (in spite of 
the fact that his power of hearing the watch is much impaired), 
that he has never been considered, by any but his most intimate 
friends, as very hard of hearing. Persons who can hear the 
watch no better than he, are usually, if not always, very much 
troubled to hear conversation, even when addressed especially 
to them ; and yet the patient in question can join in general con- 
versation carried on in an ordinary tone, and can hear lectures, 
and so forth, with perfect ease. 

My friend Dr. Khoades, surgeon in the United States Navy, 
informed me that, during an experience in several naval en- 
gagements large and small, during our late civil war, he never 
saw a rupture of the membrana tympani from cannonading. 
He has seen sailors who said they were hard of hearing from 
cannonading. These men usually complained of tinnitus. Some 
of them got better, and some worse. Sailors usually keep the 
mouth open during the firing. 

The following case also illustrates the effect of concussion of 
the labyrinth. It is possible that an injury of the labyrinth more 
readily occurs when the membrana tympani is in a relaxed 
condition, as was probably the case in this instance, the sub- 
ject being surprised by the wave of air that unexpectedly forced 
upon the endolymph. Any one who has received an unexpected 
whisper in the auditory canal, may remember how long a tin- 
nitus aurium continued which it seemed to produce. 

Case TV. — Loss of Hearing from a Kiss upon the Ear. — Mrs. H — — , aged 
forty-two, seen through the kindness of Dr. O. B. Douglas. Last winter (1878), 



CONCUSSIONS OF ACOUSTIC NERVE. WB 

her husband came up behind her as she sat reading, and kissed her suddenly 
upon the right ear, taking her completely by surprise. She suffered a great shock 
and had a roaring in the ear for some time. The incident made her very " ner- 
vous" for two or three weeks afterward. During the past summer she was told 
by her relatives that she was becoming deaf on the right side. She paid no at- 
tention to it until six weeks ago, when she tried her right ear with her watch and 
found she could not hear it. She gives satisfactory evidence of having heard a 
whisper well with the right ear during last winter and spring. Has had occa- 
sional tinnitus during the past few months after taking cold. Enjoyed music 
very much formerly, but does not now. The piano practice of the children at 
home annoys her. Whistling is particularly disagreeable.- All noises disturb 
her somewhat, so that she has " felt afraid that she was becoming nervous." 
General health is good. Menstruates regularly. No cardiac trouble detected. 
Father died of paralysis. 

H. D., R., T \ ; L., ££. 

Tuning-fork on teeth or vertex seemed louder in the left ear. Is slightly in- 
tensified in right by plugging, but much more in left. Aerial better than bone- 
conduction on each side. 

The drum-heads are about alike and show nothing to account for deafness. 
Air enters the right drum by both catheter and Politzer's method, but does not 
alter the hearing. All notes of the piano are heard, but she says they do not 
sound " clear," even with both ears open. Dr. Douglas examined the naso- 
pharyngeal space and the mouths of the Eustachian tubes and found nothing 
abnormal. 

This seemed to be a case of deafness from affection of the 
labyrinth, with no apparent canse except the kiss upon the ear. 
The concussion from the kiss may have caused the loss of hear- 
ing at once ; or, as seems more likely, it may have produced 
changes in the labyrinth, which, in combination with the general 
nervous shock, served as a foundation for a gradual loss of hear- 
ing subsequently — as, for instance, by some atrophic process. 

Mr. Hinton was inclined to think that in all instances of loss 
of hearing, apparently from slight causes, it might be found that 
some previous source of injury to the ear had existed. He quotes 
some cases to illustrate that view. He speaks of a concussion 
sometimes jarring the labyrinth, not into complete paralysis, but 
into a state of extreme liability to this condition. ! 



ANEURISM— TUMORS. 

Aneurism of the basilar artery, cerebral tumors, and. in fact. 
all varieties of intracranial disease, may cause tinnitus aurium 
and impairment of hearing ; but all such cases require special 
study, and hardly demand a detailed notice. Griesinger says 
that the symptoms of disease of the nerve, or its expansion, aris- 

1 Questions of Aural Surgery, p, 268. 



654 TOIOBS OF CEREBRUM. 

ing from aneurism, are : Difficulty in swallowing ; occasionally 
spasmodic deglutition ; impairment of hearing, or even complete 
deafness, often appearing at intervals, with great tinnitus ; dif- 
ficulty of respiration and articulation ; interference with the ex- 
cretion of urine, without any impairment of the intellectual 
functions ; and, finally, paraplegia. Ton Troltsch states that a 
constant sensation of knocking in the back of the head is also a 
suspicious symptom. 

Dr. Hughlings Jackson believes that deafness (excluding 
cases manifestly due to disease of the apparatus of hearing) is a 
rare complication of intracranial disease. It is very much less 
common than optic neuritis. Dr. Jackson has not yet seen an 
autopsy which showed that deafness had depended upon adven- 
titious products, nor upon "'any sort of disease of either cerebral 
hemisphere.*' One case : is recorded, however, which Dr. Jack- 
son quotes, of tumor of the left cerebral hemisphere, where 
there has been deafness of both ears. Dr. Jackson thinks that 
deafness does not result from intercranial tumor, or other ad- 
ventitious product, unless the auditory nerve is actually in- 
volved or pressed upon. 

According to Schwartze, 2 it has been estimated by Calmeii 
that impairment of hearing occurs in about one-ninth of all 
cases of cerebral tumors. Aural symptoms occurred, in 77 cases 
of tumors of the cerebellum, 7 times : in 26 cases of tumors of 
the pons, 7 times ; in 27 cases of tumors of the middle lobe, 3 
times ; but not once in 27 tumors of the anterior lobe, nor in 14 
cases of the posterior lobe, and 4 of the fourth ventricle. 

Deafness of one side, according to Cruveilhier, quoted by 
Schwartze, was one of the first symptoms in a number of cases 
of central tumors, Schwartze further says, that impairment of 
hearing on both sides not unfrequently occurs in tumors of the 
cerebellum, and when from the situation of the tumor we know 
that it does not press directly upon the nerve-trunk of the oppo- 
site side, nor upon its origin in the medulla, and when there are 
no symptoms of paralysis of other cerebral or spinal nerves, 
Schwartze thinks that there may be a neuritis or oedema in 
these cases. 

DISEASE OF THE SEttl-CIRCULAR CAXALS. 

In the beginning of the preceding chapter it was said, that it 
is noAv possible to diagnosticate disease of the cochlea and of the 
semi-circular canals, as distinguished from diseases of the other 

1 Royal London Ophthalmic Hospital Reports, rol. iv., part iv., p. 420. 

- Handbuch der pathologischen Anatomie, by E. Klebs. Gehororgan, by Schwartze. 



DISEASE OF SEMI-CIRCULAR CANALS. 655 

parts of the labyrinth. I think this has been shown to be true 
as regards the cochlea. As to the diseases of the semi-circular 
canals, the late P. Meniere, 1 of Paris, reported a case which has 
become classical. The deductions from it have not always been 
justified by the facts. The term Meniere's disease has been used 
so indiscriminately, especially by neurologists, that it has con- 
fused our ideas as to the significance of vertigo, nausea, and ina- 
bility to walk without staggering, when they occur in connection 
with sudden loss of hearing. In one of Meniere's cases he found 
a kind of bloody exudation in the semi-circular canals, while the 
brain, the cerebellum, and the medulla were sound. This case 
was that of a young woman, who, while menstruating, took cold 
from riding on the top of a diligence. The other cases, nine in 
number, are clinical accounts of cases of sudden deafness, in 
which it is probable that the semi-circular canals were pressed 
upon or diseased, for there was vertigo and a staggering gait. 
Some of these cases were perhaps of tympanic origin, certainly 
some were cerebral rather than aural, and the pressure upon the 
semi-circular canals was not from any exudation within them. 
As has been seen in the preceding pages, aural vertigo is by no 
means always dependent upon disease of the labyrinth. 

Meniere read his first paper upon the subject before the Acad- 
emy of Medicine in Paris, January 8, 1861, and in it he claimed 
that the lesion causing the following train of symptoms, namely, 
vertigo, dizziness, uncertain gait, nausea, followed by deafness, 
was situated in the semi-circular canals. Whether or not cases 
were all to be referred to the labyrinth as their point of origin, 
they cannot, with our present knowledge of pathology, certainly 
be referred to the semi-circular canals. There is a vertigo of 
tympanic origin, also one proceeding from primary disease of the 
labyrinth, as well as one from the cerebrum. All of these forms 
may be accompanied by sudden deafness. The deafness from 
the impaction of cerumen is sudden in occurrence, so also that 
from exudation or hemorrhage into the tympanum, as well as 
that from hemorrhage into the labyrinth. These all may be ac- 
companied by vertigo. A classification, then, which groups 
under one head of disease, all cases of vertigo attended by deaf- 
ness, is crude, and should be rejected. Each case should be 
studied by itself, when it will be possible, in many instances, by 
a careful study of the principles that have been laid down in 
this and similar works, to determine the seat and nature of the 
lesion. Meniere did an inestimable service to the profession in 
directing attention to the ear as the seat of disease, formerly 



1 Gazette Medicale de Paris, 1861, pp. 39, 55, 88, 889, B79, 507. 



656 pkessube upon semi-ciectlae canals. 

supposed to be in all cases situated either in the brain or the 
stomach. The profession must now go further and determine 
what part of the ear is affected in individual cases. 

Dr. Ormerod l has called attention to the fact, obvious to any 
one who reads Meniere's cases, that "the paroxysms of vertigo 
and vomiting are more sudden, more violent, more definitely 
paroxysmal" than the vertigo from chronic disease of the middle 
ear. and that what Hughlings Jackson calls the •'vital symp- 
toms "—perspiration, pallor, and faintness— are more marked. 
Yet. as this writer admits, the vertigo from acute disease of the 
middle ear may be paroxysmal and severe, although then the se- 
verity of the symptoms, taken in connection with others, may be 
of value in making up a diagnosis as to the seat of the lesion, it 
cannot be said to be a pathognomonic guide. As before said in 
this work, I have seen the most alarming vertigo — faintness ap- 
proaching to coma — from syringing the ear. 

Case I. — Sudden Deafness — Vertigo — Infantile Earaches — Syphilis Years pre- 
viously. — E. R-. L , aged fifty-one. November 26, 1881. The patient states 

that as he attempted to dance at a ball a year and eight months ago, he found he 
could not hear a sound. He rubbed his ears vigorously and the power of hear- 
ing returned. The next morning he had vertigo to such an extent that he could 
not get out of bed, could not even hold up his head. There was also nausea for 
a day or so. When he fi n ally got about he staggered in his gait. He has been 
an overworked man for five or six years. He had syphilis twenty-one years 
ago — chancre, eruption, alopcecia, sore throat. H. D., Eight ear, *-*? f- : left. --.-. 
Bone conduction is better than aerial on the right side. The aerial is the same 
as bone on the left. Hears worse in a noise. Eight membrana tympani, poor 
light spot ; left opaque, light spot only on periphery. His head is now improv- 
ing. Tinnitus aurium is not very troublesome. TVhen he had vertigo, the sensa- 
tions were of turning to the right. Xo vertigo for the past six or seven weeks. 
The second examination showed that the aerial conduction was better on each 
side. There is a history of earaches as a child. The druni-heads are cicatricial. 
He has been subjected to thorough treatment by mercury several times, he says. 
His ears feel better after inflation. 

This was a case of chronic disease of the middle ears, in 
which the labyrinth, especially the semi-circular canals, became 
secondarily affected, by pressure, it may be supposed, and not 
from any disease in them. To call such a case one of Meniere's 
disease, is not to give any very definite idea of its nature. The 
history of earaches, the appearance of the drum-heads, the syphi- 
litic disease of years before, combine to give us an accurate no- 
tion of the causes and nature of the disease. 

Case LT. — Sore Tier oat — Great Loss of Hearing — Inability to Walk Straight. — 
General X , aged forty-four. Seven years ago while he had a sore throat, 

1 Brain, voL vi., p. 33. 



PEESSUEE UPON SEMI-CIRCULAR CANALS. 657 

lie found himself very hard of hearing, with inability to walk straight. "He 
could not control his lower limbs." Noise made his hearing much worse. Hear- 
ing distance : Right ear, - 4 \ ; left, {%. Aerial conduction better than by bone on 
left side. Both drum-heads are tympanitic. He can now walk pretty well. 

In this case there may have been a tympanic hemorrhage, such 
as I have seen in the course of acute catarrh, which caused the 
want of ability to walk — for I have seen failure of power of main- 
taining the equilibrium from such a cause — or the lesion may 
have been in the medulla. That it was of tympanic origin seems 
to me more probable. The proper way to describe cases of ver- 
tigo and inability to walk straight in cases of aural disease is to 
speak of them as of peripheric (external auditory canal), tym- 
panic, labyrinth or cerebral origin. It is possible in many cases 
to make such an analysis of the cases of pressure upon, or dis- 
ease in, the semi-circular canals. These cases are not of the 
severe type of those presented by Meniere, but they are such as 
are constantly, as it seems to me, improperly and insufficiently 
described by this name. More serious cases of the same charac- 
ter may be found in other parts of this book. 

EPILEPSY AND AURAL DISEASE. 

The relation of aural disease to epilepsy, has been mentioned 
in the discussion of foreign bodies and ear cough, but it cannot 
be said that the subject has yet been fairly studied, except from 
the point of the reflex origin of epilepsy from suppuration of 
the tympanum, foreign bodies in the auditory canal, and so forth, 
although I have seen cases of epilepsy apparently caused by such 
diseases, and I have also seen epileptics who suffered from 
chronic non-suppurative disease of the middle ear. Ormerod 
found that of 100 cases of undoubted aural disease, as deter- 
mined by Dr. Urban Pritchard and Mr. Cumberbatch of St. Bar- 
tholomew's Hospital, "seven had had bona fide epileptic fits." 
This the writer states is a large proportion, for Memeyer, as 
he says, estimates that there are only six cases of epilepsy to 
every 1,000 persons, while Russell Reynolds maintains that this 
estimate is far too high. I have no doubt, as suggested by 
Ormerod, that aural disease and disease situated not only in the 
peripheric portions, but in the labyrinth, may excite epilepsy ; 
but more investigation is required upon this subject. 

Pathology. — In passing over the subject of the causes of dis- 
ease of the internal ear, we have alluded to the pathology of the 
affection ; but it may be well to tabulate the post-mortem ap- 
pearances that have been found in the labyrinth. Inasmuch as 

42 



658 PATHOLOGY OF INTERNAL EAR. 

very few of these appearances have been accompanied by the 
history of the case, they have not the importance that they 
would otherwise have had. Yet they may be of service as a 
basis for future investigation. 

Absence of auditory nerve 1 

Atrophy of auditory nerve 10 

Suppuration -. 1 

Tumor upon 1 

Hemorrhage upon 2 

Thickened membranous labyrinth 11 

Atrophy of membranous labyrinth 22 

Congestion 1 

Suppuration of membranous labyrinth 3 

Serum in labyrinth 3 

Opaque fluid in labyrinth 3 

Black pigment-cells too abundant 5 

Distention of blood-vessels of cochlea 3 

Fluid, opaque ■ 4 

Pus in cochlea 1 

Thickened lamina spiralis 1 

Osseous wall of semi-circular canals incomplete 3 

Enlargement and congestion of blood-vessels (Hinton ] ) 4 

Hypereemia of the various parts, or of the whole contents 
of the labyrinth, has been found in typhus and puerperal fever, 
in acute tuberculosis, and in cases of poisoning by carbonic 
oxide gas ; also in meningitis, and in cases of disturbances of 
circulation from disease of the heart, and in emphysema of the 
lungs. Hypersemia of the labyrinth may result from vaso-motor 
disturbances of innervation. 

According to Erb, 2 atrophy of the acoustic nerve occasionally 
occurs in tabes dorsalis. 

Tumors — sarcoma, neuroma, and gummata — may enter the 
meatus auditorius interims* 

Treatment. — In addition to what has already been said as to 
the treatment of disease of the internal ear, it may be proper to 
add, that before any treatment is entered upon, the situation of 
the lesion and its cause should be made out if possible. With- 
out this all treatment will be like working in the dark, and 
worse than useless. True inflammation of the membranous 
labyrinth should be treated by absolute quiet and rest, leeches 
to the mastoid and tragus, pedeluvia, and purgations. The use 
of quinine and cold applications to the head should be avoided, 

1 Questions of Aural Surgery, p. 255. 

2 Ziemsseu's Haudbuch, p. 142. 



TKEATMENT OF INTERNAL EAR. 659 

as well as all inflations of the tympanum. Syphilitic affections 
of the labyrinth, if treated at an early stage and vigorously, by 
the mercury and iodide of potassium treatment, may recover. 
Traumatic affections of the labyrinth are usually hopeless from 
the start, as far as restoring the hearing is concerned ; but much 
can be done by quiet, leeches, counter-irritation and the like in 
removing the symptoms of tinnitus, vertigo, double hearing, and 
so forth. 

Chronic affections of the labyrinth are, unless of a syphilitic 
origin, so far as my experience goes, utterly hopeless. Elec- 
tricity has a much-vaunted reputation, among inexact observ- 
ers, for its cures of nerve-deafness ; but there are no authentic 
cases on record of a cure of a true inflammatory affection 
of the labyrinth by this agent. The only seeming exception 
to this rule is a case reported by Moos, 1 which he entitles " Re- 
covery from Complete Nervous Deafness." The constant cur- 
rent was used successfully in what seems to me to have been a 
case of impairment of hearing occurring in the course of an 
hysterical affection. The patient had acute articular rheuma- 
tism, and in the fifth week hysterical symptoms appeared. 
There was great sensitiveness of the ear, such as occurs in other 
parts of the body in hysterical women, and increased hearing 
power. The patient lay for nine days without moving on the 
right side, and thus an ulcer of the concha was caused. She 
took large doses of quinine for these nine days, when impairment 
of hearing occurred, and continued to increase until the patient 
was communicated with in writing. In the eleventh week te- 
tanic spasms occurred. The galvanic current was then em- 
ployed, twelve elements being used. The symptoms, except 
the deafness, soon subsided, and a thorough course of galvani- 
zation of the ears restored the power of the right one perfectly, 
and of the left in all respects, except the inability to distinguish 
the highest note of the seven-octave piano. 

I confess I do not feel the enthusiasm over this case which is 
exhibited by Professor Moos, which, according to his hopes, is to 
" toll the knell for all the opponents of the therapeutic value of 
electricity in aural disease." In my opinion the loss of hearing 
was caused by the quinine, and the partial recovery due to the 
fact that its use was suspended. 

Beard and Rockwell 2 give their views as to the value o\ elec- 
tricity in the treatment of diseases of the auditory nerve and 
labyrinth in the following cautious language: "Cases of uerv- 

1 Archives of Ophthalmology and Otology, "Rd. L, No. 2. 

3 A Practical Treatise on Medical and Surgical Electricity, pp, 571-78. 



660 TREATMENT OF INTERNAL EAR. 

ous deafness, or of deafness resulting from various pathological 
conditions, with which a morbid condition of the auditory nerve 
is complicated, and all cases of tinnitus aurium, whatever may 
be their supposed pathology, should only be regarded as hopeless 
after the failure of persevering and varied treatment by elec- 
tricity, although perfect or approximate cures will be obtained 
only in a small percentage of the cases. The treatment of opac- 
ity and thickening of the drum, and of chronic inflammation 
(with the consequent adhesions and other morbid changes) of 
the middle ear and Eustachian tube, offers a fair and important 
field for electrical experiment." 

Dr. Knapp says: 1 "I have tried it electricity in nearly all 
reported cases, but ivithout a shade of improvement." 

Dr. Sexton writes me that he has experimented with electri- 
city in aural disease for two years, both in private and public 
practice. He is convinced of the correctness of Brenner's for- 
mula ; but in all his cases, Dr. Sexton says, "there was no marked 
improvement in the hearing." "Ina few cases of impaired hear- 
ing, where there were the accompanying symptoms of dizziness 
or nervous headache, the advantages of the treatment were de- 
cided." 

My own experience has been purely negative. I have never 
seen any improvement, in any forms of nerve-deafness, from 
the use of electricity in any form. I fear that we must abandon 
the hopes entertained by some, of the powers of this subtle agent 
in those as yet mysterious diseases, the affections of the inter- 
nal ear. 

The anaemia of the labyrinth that sometimes occurs after 
typhoid fever, and perhaps after other serious diseases of an ex- 
haustive character, may be successfully combated if it be not 
treated by the usual means for disease of the middle ear. In- 
flation, either by the catheter or Politzer's method, should be 
avoided. Counter-irritation over the mastoid, and tonics will 
often be of service ; while quinine, salycilic acid, and other agents 
which excite tinnitus aurium should be avoided. The patient 
should be kept away from noisy places, and avoid any exposure 
to loud sounds. It is well to cause such subjects ; on going into 
the open air during convalescence, to wear cotton or wool in 
the external meatus, in order to protect their ears from the 
shock of noises. 

1 Archives of Ophthalmology and Otology, vol. ii., No. 1. 



DEAF-MUTEISM 



AND 



MECHANICAL ASSISTANCE TO THE HEARING. 



CHAPTER XXIII. 

DEAF-MUTEISM— MECHANICAL ASSISTANCE TO THE HEAEING. 

Acquired and Congenital Cases.— At what Age are Children Conscious of Sounds ? — 
Causes. — Tables of Examination of 147 Cases. — Hearing-trumpets. — Audiphone. 

There is no logical reason for the discussion of deaf-muteism 
in a treatise upon the diseases of the ear, as a subject apart by 
itself, any more than there is for the consideration of blind- 
ness in a work upon the eye. But long-established custom 
among writers on otology renders it proper that a few pages 
should be given to this important theme in this text-book. I 
shall, however, say nothing upon methods of instruction of deaf- 
mutes, but refer my readers to the appropriate treatises and au- 
thorities for knowledge on this subject. 

Deaf-muteism is caused by diseases of the middle and inter- 
nal ears. These diseases are of various kinds, and have been 
fully discussed in the preceding chapters of this work. The 
only reason that deaf persons become mutes is that the disease 
of the ear occurs either before birth, or so shortly after, that 
its victim is unable to learn to imitate speech. There are no 
changes in the larynx that prevent deaf-mutes from articulat- 
ing distinctly, except those that may possibly come from disuse 
of the organ. 

Persons who become completely deaf later in life, do not lose 
the power of speech ; but they usually speak in an unnatural 
tone, because they are unable to hear their own voice with dis- 
tinctness. Deaf-mutes may be divided into two great classes. 

I. — The acquired cases, or those in whom the disease of the 
ear has occurred after birth, from some traceable cause. 

II. — The congenital cases. 

It is very difficult to come to a correct conclusion as to the 
relative frequency of congenital and acquired deaf-muteism. 
The tables that are made up by the directors of schools for the 
deaf and dumb are not trustworty, because they arc taken from 
the statements of persons who are seldom exact observers — the 
parents or friends of the children. The late Dr. George M. 



664 DEAF-MUTEISM. 

Beard and myself ' examined two hundred and ninety-six cases 
of deaf -muteism, with their histories, in the schools of New York 
City, and Hartford, Conn., and the result of our examination 
was, that about sixty-one per cent, of these cases were probably 
congenital, and that the remaining thirty-nine per cent, were 
acquired. Wilde's statistics show that about fifty per cent, are 
of the acquired form. The exact truth as to the time when the 
deafness occurred is something very difficult to ascertain. It is 
not easy to learn, even when great pains are taken by persons 
well competent to observe, whether a very young infant hears 
well or not, although we may easily satisfy ourselves whether 
or not loud sounds are perceived. 

Children appear to be conscious of sounds during the first 
days of their life, while at the third month they show an appre- 
ciation of particular sounds, such as chirping, whistling, and the 
like. From the first month to the third is perhaps the earliest 
period at which an opinion can be formed as to the hearing of 
an infant. I find on inquiry among mothers, that their opin- 
ions vary excessively upon this point. Some affirm that they can 
decide whether their children have good hearing within a few 
days of their birth, while others say that a month or two is re- 
quired. Infants seem to hear sounds conducted through solid 
media almost immediately ; that is, within a few days after birth, 
while hearing of tones through the air appears much later. They 
will very soon notice a jar, such as a stamp on the floor, while 
for the human voice time is needed. Moreover, an inflammation 
of the ear, if not of the suppurative variety, may run its entire 
course in a young child, and never be recognized by physician 
or friends as a case of aural disease. It is well known, and the 
fact has been before alluded to in this volume, that a suppurative 
inflammation of the middle ear, in an infant, is sometimes first 
recognized as such when the pus breaks through the membrana 
tympani. The fact that such severe processes may go on in the 
ears of children, and escape recognition, renders it very probable 
that even Wilde's proportion, in which he gives fifty per cent, as 
the proper one for acquired deaf -muteism, is too low a one. I 
am inclined to think that there are many more cases of children 
becoming deaf after birth, than of intra-uterine deafness. 

It does not require absolute deafness in a young child to pro- 
duce deaf -muteism. A case of chronic aural catarrh, that would 
only inconvenience a grown person, will make an infant so stupid 
that it will soon cease to attempt to imitate speech. We have 
all grades of hearing power in so-called deaf-mutes. I have 

American Journal of the Medical Sciences, vol, liii., p. 401. 



DEAF-MUTEISM — CAUSES. 665 

seen two or three cases of children who were being educated in 
deaf and dumb asylums, who could hear words spoken into their 
ears in a very loud tone. In one case the parents found it too 
much trouble— inasmuch as no physician could be found who 
would treat the suppurating ear—to teach their child to speak. 
He was consequently losing his, speech, and also having his life 
placed in peril by the neglect of the ulcers in his ears. 

Some asylums for the deaf-mutes in this country are not at- 
tended by physicians competent to examine and treat the ear. 
Many of the inmates require constant and special care of their 
ears ; especially is this true of those affected with suppuration of 
the ears, of whom there are about twenty per cent, in the asy- 
lums. A certain and valuable degree of hearing might be ob- 
tained in a few of these cases by intelligent local treatment. 

Deaf-mutes should be taught to speak by imitation of the lips 
of the speaker. The sign language has been for so many years 
the means for educating deaf-mutes in this country, that lip 
training has not yet obtained its proper place with us ; but it is 
fast winning it. The next generations will exhibit many more 
deaf-mutes who can converse with any member of society, and 
who will not be limited to the comparatively few who know the 
language of signs. I know an accomplished young lady, entirely 
deaf from acute suppuration of the middle ears, with whom I 
have often conversed, who takes her full part in the conversa- 
tion of a large family. 

Causes. — The causes of deaf-muteism are very graphically 
set down in the reports of deaf and dumb asylums, but unfortu- 
nately these assigned causes are usually incorrect. Thus, "colic," 
"a burn," "a fall," "fits," "mother marked," ' etc., figure in 
such tables as causes of deaf-muteism. Many of the so-called 
facts in such tables have been derived from unscientific obser- 
vers, who sometimes have very positive opinions as to the 
causes of disease, and who believe that in a severe fright to the 
mother, the marriage of cousins, etc., ample causes are found 
for deaf-muteism. The investigation of the proximate causes 
of deaf-muteism show, as has been said, that their victims have 
become deaf from precisely the same kinds of diseases, and in 
about the same proportion, as obtains in impairment of hearing 
or deafness occurring at a time of life that prevents the subjects 
from becoming dumb as well as deaf. Of the 296 cases exam- 
ined by Dr. Beard and myself, in only 22 cases was the drum- 
head found to be normal, and in 200, or more than two-thirds of 



^n tlie Etiology of Acquired Deaf-Muteism, by Clarence J, Blake. Reprint from 

Boston Medical and Surgical Journal. 



66Q DEAF-MUTEISM — CAUSES. 

the whole number examined, there was chronic pharyngitis or 
tonsillitis. Of the 114 acquired cases, the membrana tympani 
was perforated in 29 cases. Thus, suppurative inflammation 
does not seem to cause as large a proportion of deaf-muteism 
as is usually supposed. In some of the cases, however, the 
membrana tympani had once been perforated and had healed. 
In Blake's statistics, 1 forty per cent, of those examined, 41 in 
number, were classed by him as acquired cases. In VI of these 
acquired cases the membrana tympani was perforated or de- 
stroyed on one or both sides. In 13 of the 17 cases, the deafness 
was traceable to the pharyngitis of scarlet fever or measles. 

The remote causes, or the causes that tend to produce dis- 
ease of the ears in intra-uterine or infantile life, form a very in- 
teresting study, but we have as yet no very accurate data upon 
which to discuss them. It is an open question, perhaps, whether 
intermarriage tends to produce disease of the ear in young sub- 
jects or not, whether it tends to lead to arrested development in 
young children ; for there is no doubt that some cases of con- 
genital deafness depend upon want of proper development of 
the auditory nerve and labyrinth. I was informed at Hartford, 
that a certain part of our country, which is somewhat isolated 
from the other parts of the Union, and where intermarriages 
are the rule, furnished a proportionately large contingent of 
cases of congenital deaf-muteism. The cases from this district 
that I saw were in persons somewhat deficient in intellect, and 
we may consider their etiology as identical with that of idiocy, 
feeble Drains, or partial development of other parts of the body, 
such, for example, as spina bificlis, coloboma iridis, etc. It is not 
probable that deaf-mute parents are likely to beget children who 
do not hear, for the simple reason that in the large proportion of 
cases, the deafness depends upon inflammatory action, which is 
not transmitted, except possibly as a tendency or by anatomical 
conditions. Deafness dependent upon imperfect development of 
the ear or brain may be inherited. 

Voltolini's inflammation of the membranous labyrinth is 
probably one of the proximate causes of acquired deaf-muteism. 
Von Troltsch showed that a purulent process is a very common 
appearance in the tympanic cavities of half-starved foundlings. 
I suppose that the mal-nutrition of parents may be traced as re- 
mote causes for such affections of the middle ear. 

We may sum up the causes of deaf-muteism, as developed in 
clinical histories and in examinations on the dead subject, as 
follows : 

1 Keprint from Boston Medical and Surgical Journal. 



DEAF-MUTEISM — CAUSES. 667 

1. Inflammation of the middle ear, resulting in suppuration, 
or adhesions, anchylosis of the ossicula auditus, and so forth. 

2. Inflammation of the nerve or labyrinth, resulting in sup- 
puration or thickening of the membranous labyrinth, deposits 
in it, and so forth. 

3. Arrested development, or absence of some parts of the es- 
sential part of the auditory apparatus. 

These are the causes which are shown in the table given by 
Moos, 1 in his account collected from various authorities, of sec- 
tions of the ears of sixty deaf-mutes, and they agree well with 
the clinical examinations and histories. 

Treatment. — There is certainly no peculiar treatment neces- 
sary for the deafness of young children, which renders them 
mute, because they cannot learn to imitate speech ; but I cannot 
refrain from alluding to the lingering remains of the barbarism 
of the past centuries, which neglects the care of the ulcerated 
membrana tympani, and the swollen throats of the poor mutes 
who suffer from chronic suppuration and catarrh of the middle 
ear. Although the educational wants of deaf-mutes are now 
well attended to, their medical treatment is sadly neglected in 
the asylums and schools of our country, as well as at their homes. 
It was not until the seventh century that the deaf-mutes were 
thought worthy of an education. The twentieth century will 
probably arrive before every school or asylum for these unfortu- 
nates has in attendance a physician who knows how to examine 
and treat a diseased ear. These schools are not hospitals, it is 
true ; but there is always in them quite a large proportion of 
young patients who still suffer from a disease which, although 
it has fully destroyed the hearing, is not yet stayed, and which 
often goes on to destroy life. I refer, of course, more particu- 
lary to the suppurative forms of disease. 

According to the census of 1880, there were in the United 
States 33,878 deaf-mutes. Of these we may believe that fifty per 
cent, belong to the acquired cases. How many of these belong 
to what may fairly be called preventable diseases, it would not 
be possible to say ; but certain it is, that if diseases of the ear 
had always rejoiced in the same attentive treatment as many of 
the less essential parts of the body have received, the number of 
these unfortunate mutes would have been greatly lessened. 

The following table shows the results of an examination of 
the hearing power and membranse tympani of 147 deaf-mutes, 
with a statement of the causes assis^ 

1 Klinik dor Ohrenkrankheiton, p. 341. 

"Archives of Otology, vol. xiii., Xo. 1, March, 1884. 



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676 



EXAMINATION OF DEAF-MUTES. 



13 

s 


Constant offensive dis- 
charge from both ears. 
Eczematous eruption 
in both auricles. 

Has convergent con- 
comitant squint. 

Bone conduction on 

forehead. 
Tuning-fork negative on 

hand. 

Eemembers that at one 
time he could hear. 

Says " No " as to tun- 
ing-fork on hand. 

Says ''No," in answer 
to question regarding 
perception of tuning- 
fork on hand. 


c3 

11 

s s 


Congested along 
handle and upper 
border of mal- 
leus. 

Absent, granula- 
tions in tympanic 
cavity. 

Opaque, no light 
spot. 

Cicatricial. 

Cicatricial. 

Opaque, no light 
spot. 

Cicatricial. 

Sunken, a point-like 
light spot. 

Neoplastic, red in 
centre. 
Neoplastic. 

Perforation, no dis- 
charge. 


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Sunken. 

Absent, granulations 
in tympanic cav- 
ity. 

Opaque, no light 
spot. 

Absent, slight dis- 
charge from tym- 
panic cavity. 

Absent, tympanic 
cavity granular. 

Opaque, no light 
spot. 

Ulcerated. 

Sunken, a point-like 
light spot. 

Neoplastic, perfor- 
ated. 

Very thin, neoplas- 
tic. 

Obscured by epider- 
mis. 


Left 
bone 
conduc- 
tion. 


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Cause stated by parents 
or guardians, and age 
at which they say 
deafness appeared. 


" Scarlet fever at 1 
year and 4 mos." 

" Scarlet fever at 4 
years." 

' ' Scarlet fever at 3 

years. " 
" Scarlet fever at 4 

years." 

"Scarlet fever at 5 

years." 
" Scarlet fever at 3 

years." 
' ' Scarlet fever at 2 

years and 3 mos." 
"Scarlet fever at 3 

years." 

"Scarlet fever at 6 

years." 
" Scarlet fever at 4| 

years." 
" Scarlet fever at 3 

years." 


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EXAMINATION OF DEAF-MUTES. 



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684 STATISTICS OF DEAF-MUTEISM. 

The following table shows the statistics of deaf-mutes in this 
country in 1880 : 

Total 33,878 

Males 18,567 

Females 15,311 

Native 30,507 

Foreign 3,371 

White , 30,661 

Colored 3,217 

Total population of the United States : 

Native 43,475,840 

Foreign , 6,679,943 

50,155,783 

In the year 1867, in conjunction with the late Dr. George M. 
Beard, I examined 296 deaf-mutes with a view of contributing 
something to our knowledge of the causes of deaf-muteism. The 
results of these examinations were meagre, and they were made 
to appear even less complete than they were in reality, because 
the editor of the journal in which they were published ' could 
not give us the space to publish the tables upon which our con- 
clusions were founded, and because the tables were lost so that 
they could not be published elsewhere. Since the use of the 
tuning-fork has come to play such an important part in aural 
diagnosis, it has been made available also in the examination of 
deaf-mutes. De Rossi, 2 of Rome, has made the most complete 
examinations of which I know, as to the hearing power of deaf- 
mutes. He examined seventy individuals with the speaking- 
tube and tuning-fork. Twenty- seven heard the voice, four the 
watch, thirty-nine the tuning-fork vibrating in the air. Nearly 
all of the seventy perceived the vibrations through the bones, 
eleven only had no perception by bone-conduction, and De Rossi 
found only three cases of what he termed total deafness. These 
examinations of De Rossi seem to me to furnish more reliable 
data than the cases of Toynbee and Kramer, and chiefly because 
the examination by the tuning-fork and speaking-tube was not 
made by them. Accordingly, I have imitated the examinations 
of De Rossi in those I have made. The imitation was an uncon- 
scious one, however, for it was not until I had nearly finished 
my examinations, that I found from a scanty reference in Hart- 

■ S3> 

1 American Journal of the Medical Sciences, vol. liii., p. 399. 

" Eelazione sopra 1' Ospizio dei Sordi-Muti de Roma. Quoted by Hartmann. 
"Deaf -Mutism." Translation, p. 84. 



CAUSES OF DEAF-MUTEISM. 685 

mann'sbook on deaf -muteism, that De Rossi had preceded me in 
these tests. 

The tuning-fork seems to me a very important means of de- 
termining- the seat of the lesion, in cases of impairment of the 
hearing in which muteism does not result. I was desirous to 
know what it would indicate in those who are dumb as well as 
deaf. I found in the institution for the improved instruction of 
deaf-mutes in this city, the most ample opportunities for exam- 
inations. Every facility was afforded me by the principal, Mr. 
Greenberger, and I desire to thank him not only for the advan- 
tages he so liberally afforded me, but also for his valuable assist- 
ance given in a truly scientific spirit. I was also assisted by 
Dr. J. B. Emerson and Dr. George J. Bull, without whose aid I 
should not have been able to accomplish the work of examining 
so many pupils. I used a " C 2 " tuning-fork in the examination 
as to the aerial and bone-conduction. The tests by speaking- 
tube were made by Mr. Greenberger, and I have relied wholly 
upon his statements as to that point. 

Table I. — One Hundred and Forty -seven Cases of Deaf- Muteism [causes stated by 

parent or guardian). 



Born deaf 44 Whooping-cough 2 

Cerebro-spinal meningitis 27 Spinal trouble 1 

Scarlet fever 16 Mumps 2 

Brain fever 13 Pneumonia 2 

Meningitis 4 Gastric fever 1 

Measles 7 Cholera infantum 1 

Fall on head 7 Intermittent fever 1 

Unknown 7 Syphilis 1 

Convulsions 4 Varioloid 1 

Hydrocephalus 3 

Fever 3 147 

In regard to this table, I can only say that it is as reliable as 
any that it seems possible to get from any institution. As far 
as the statements as to scarlet fever, measles, cerebro-spinal 
meningitis, meningitis, mumps, and syphilis go, I think it may 
be considered trustworthy. When we enter the domain of con- 
genital deafness, or such causes as "spinal trouble," "fall on 
head," "convulsions," there is great uncertainty as to the actual 
cause. Yet these causes are taken from blanks carefully rilled 
out by the parents or guardians, many of them very intelligent 
people of the higher walks of life, who send their children to be 
under Mr. Greenberger's care. The causes are more accurately 



686 CAUSES OF DEAF-MUTEISM. 

given, than in the other institutions in which I have made ex- 
aminations. It will be seen there were only fifty-one cases, add- 
ing together the congenital and "unknown," or a little more 
than thirty per cent., which may, with much probability, be con- 
sidered congenital cases. In our tables of 1867, we classified 
sixty -one per cent, as congenital cases. Hartmann's tables 1 
show that of 8404 deaf-mutes 5546, or more than sixty-five per 
cent., were considered as congenital cases. His statistics are 
apparently made up largely of official and not personal examina- 
tions ; for in the examinations made in Berlin by Hartmann him- 
self, one hundred and eighty-five in number, only forty-five are 
classified as congenital cases ; and those made by Cohn, in Bres- 
lau, show about the same proportion — that is, of one hundred 
and thirty deaf-mutes, fifty-seven are said to have been born 
deaf, while in other parts of Germany, and in Ireland, the pro- 
portion of congenital cases is much larger. I regard the official 
tables of all countries as valueless, except as to the total number 
of deaf-mutes. Those who collect them, are usually entirely 
incompetent for the sifting of evidence necessary to get even 
approximate truth upon this point. 

Table IL — Results of the Examination with the Tuning-fork C 2 of One Hundred 
and Forty-seven Deaf -Mutes. 

There was no aerial conduction on either side, while bone con- 
duction existed in 74 

Bone conduction on one side, both bone and aerial on the 

other, in 1 

No bone or aerial conduction on one side, bone conduction on 

the other , 10 

Bone and aerial conduction, both sides 7 

Bone and aerial conduction on one side, bone on the other 13 

Neither bone nor aerial conduction on either side 12 

No bone or aerial conduction on one side, both bone and aerial 
on the other 1 

118 

In twenty-nine cases the subjects were too young or were 
otherwise incapacitated for intelligent answers : hence no con- 
clusions could be formed, except that the large majority of 
them probably heard the tuning-fork by bone conduction. 

I will now present a series of tables made in consonance with 
the supposed cause of the deafness. 

1 Loc. cit. , p. 64. 



CAUSES OF DEAF-MUTEISM. 687 



Table III. — Scarlet Fever being Cause of Deafness, Condition of Membrana Tyrn- 

pani (16 cases, 32 ears). 

Absent 1 

Opaque and cicatricial 4 

Sunken, opaque, small or no light spot 11 

Perforate and ulcerating 9 

Congested , 2 

Neoplastic and perforate 1 

Neoplastic 2 

Not well seen 1 

Perforate, no discharge 1 

32 

Tuning-Fork Test. 

No aerial conduction but bone conduction 17 

Bone and aerial conduction 3 

No bone or aerial conduction 8 

Unreliable 4 

32 
Age of patients at time of becoming deaf : 

From 2 to 3 years 2 

" 3 "4 " 8 

" 4 " 5 " 3 

" 5 " 6 " 1 

" 6 "7 " . ., 1 

" 8 " 9 " 1 

16 

There is in these scarlet fever cases a large proportion — 8. or 
one in 4 — where disease of the nerve certainly existed. It will 
also be remarked that there is a large proportion of cases of 
ulcerative disease. That an ulcerative disease of the tympanum 
may more readily involve the internal ear than a plastic or catar- 
rhal inflammation, is probably true. Yet the starting-point of 
otitis in scarlet fever is usually the middle ear. 

Table IV. — Measles Cause of Deafness, Condition of Membrana Tympani (7 coses, 

14 ear*). 

Sunken, no light spot, opaque 5 

Congested 1 

Sunken light spot 1 

Not well seen 5 

Opaque, but good light spot 2 

14 



CAUSES OF DEAF-MUTEISM. 

Timing-Fork Test. 

Bone conduction but no aerial conduction 6 

Bone and aerial conduction , 1 

No bone or aerial conduction 1 

Unreliable 6 

14 

It will be noted that only one case occurs here of those of 
whom a reliable test could be made, in which it is possible that 
disease of the nerve alone exists — that is, the case in which there 
was neither bone nor aerial conduction. 

Age at which deafness occurred : 

Under 1 year 3 

From 1 to 2 years 3 

" 2"3 " 1 



Table V. — Cerebrospinal Meningitis Cause of Deafness, Condition of Membrana 
Tympani (27 cases, 54 ears). 

Cicatricial 6 

Opaque 6 

Sunken, fair light spot 10 

" good color 8 

' ' small or no light spot 16 

Not well seen 3 

Opaque, good light spot 1 

Cicatricial and perforate 2 

Congested and sunken 1 

Congested 1 

54 

Tuning-Fork Test. 

Bone conduction only, no aerial conduction 34 

Bone and aerial conduction 5 

Neither bone nor aerial conduction 8 

47 
Unreliable , 7 

Here the proportion of cases in which it may be conjectured 
that the nerve alone is involved, was not as large even as in 
scarlet fever. There were only eight ears of a total of fifty- 
four, or about one in seven. It . is in this disease, that an affec- 
tion of the nerve has been often assumed to be the most frequent 
cause of the deafness. 



CAUSES OF DEAF-MUTEISM. 080 

My clinical experience has been against this view, and I 
believe that the few post-mortem examinations that have been 
made of persons with aural disease in cerebrospinal meningitis, 
go to support the view of that experience, which is that a lesion 
beginning in the middle ear, is in a large percentage of cases the 
cause of the deafness. 

Table VI— Deaf ness said to be Gongential, Condition of Membrana Tympani (44 

cases, 88 ears). 

Normal color and light spot H 

Sunken, opaque, or no light spot 34 

Obscured by wax 10 

Opaque, large light spot 1 

Sunken, opaque, but good light spot 14 

Congested, sunken, and small light spot 5 

Obscured by narrow canal g 

Cicatricial and perforate .... 3 

Opaque, calcareous 1 

88 
Tuning-Fork Test. 

Bone conduction, but no aerial 48 

Bone and aerial „ o 

Neither aerial nor bone 14 

Unreliable -to 

88 
Here the proportion of cases of apparent nerve or central 
disease is quite high— fourteen to forty-eight, or a little more 
than one to three. 

Table VII.—" Brain fever," « Inflammation of Brain," "Meningitis," and « Con- 
gestion of Brain" said to be the Cause of Deafness, Condition of Membrana 
Tympani (15 cases, 30 ears). 

Sunken, opaque, small, or no, or double light spot 12 

Normal -. 

Sunken, good color, good light spot 7 

Cicatricial 

Not well seen ..» 

Perforate and ulcerating 3 

_ 

30 

Tun ing-Fork Test. 

Bone conduction only to 

Aerial and bone 4 

Uncertain g 

30 
44 



690 CAUSES OF DEAF-MUTEISX. 

Age of patients when deafness occurred : 

Less than 1 year 2 

From 1 to 2 years 5 

1 

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1 

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Table "VJLLL. — Fall on Head Cause of Deafness, Condition of Membrana Tympani 

(7 cases, 14 ears). 

Not well seen 5 

Sunken, opaque, fair or good light spot , 2 

Sunken, no light spot 2 

Good Hght spot but sunken 2 

Sunken, congested , 1 

Good light spot 1 

Small " " 1 

14 

Tuning -Fork Test. 

Bone conduction only 8 

Neither bone nor aerial 1 

Bone and aerial conduction 1 

Unreliable 4 

14 

Table IX. — Cause Unknown (7 cases, 14 ears). 

Opaque, sunken, good light spot 4 

Not well seen 1 

Opaque 1 

Good color, fair light spot 1 

Small light spot 1 

Opaque and sunken 2 

Sunken, small light spot 2 

" good light spot 1 

Opaque, good light spot 1 



14 



Tuning-Fork Test. 



Bone conduction only 10 

Uncertain 4 

14 



CAUSES OF DEAF-MUTEISM. 691 



Table X. — Convulsions Cause of Deafness, Condition of Membrana Tympani 

(4 cases, 8 ears). 

Opaque, small light spot, good color 2 

" sunken, good light spot 2 

Opaque 2 

" small light spot 2 

8 
Tuning-Fork Test. 

Bone conduction only . . „ 5 

Aerial and bone conduction 3 

8 

Age at which deafness occurred : 

Less than 1 year 1 

From 1 to 2 years 3 

4 

Table XI. — Syphilis Cause of Deafness, Condition of Membrana Tympani (1 

case, 2 ears). 

Eight much sunken, no light spot ; left slightly sunken, medium-sized light 
spot. 

Tuning- Fork Test. 
Eight, no aerial conduction, but bone conduction ; left, same. 

In this case, the only one found, there was a syphilitic his- 
tory ; notched teeth ; the subject has had interstitial keratitis. 
The disease seems to be confined to the middle ear. 

Table ~X11.—Hydi'0cep7ialus Cause of Deafness, Condition of Membrana Tympani- 

(3 cases, 6 ears). 

Not well seen 1 

Sunken, perhaps perforate 1 

" small light spot 2 

Opaque, no light spot 2 

6 

Tuning-Fork Test. 

Bone conduction only 6 

Age: 

Less than 1 year 1 

From 1 to 2 years 1 

Unknown 1 

3 



692 CAUSES OF DEAF-MUTEISM. 



Table XIII. — Spinal Meningitis Cause of Deafness, Condition of Menibrana Tym- 

pani (3 cases, 6 ears). 

Not well seen ., 2 

Sunken, opaque, good light spot 1 

Opaque and cicatricial 1 

Sunken, no light spot 2 

6 

Tuning-Fork Test. 

Bone conduction only 6 

Age: 

From 2 to 3 years 1 

" 5 "6 " 1 

" 6 " 7 " 1 

3 

Table XIV. — Varioloid Cause of Deafness, Condition of Membrana Tympani 

(1 case, 2 ears). 

Not well seen 1 

Good color, good light spot, sunken 1 

2 
Tuning-Fork Test. 

Aerial and bone conduction 1 

Bone conduction only 1 

2 
Age at which deafness occurred : one year and four months. 

Table XV. — Pneumonia Cause of Deafness, Condition of Membrana Tympani 

(2 cases, 4 ears). 

Sunken, small light spot 1 

Not well seen 1 

Opaque, sunken, no light spot 2 

4 

Tuning-Fork Test. 

Bone conduction only 2 

Uncertain 2 

4 
Age : 

Less than 1 year 1 

From 1 to 2 year3 , 1 

2 



CAUSES OF DEAF-MUTEISM. 693 



Table XVI. — Whooping- Cough Cause of Deaf ness, Condition of Membrana Tyrn- 

pani (2 cases, 4 ears). 

Good light spot, sunken, opaque 1 

Opaque, small light spot 1 

Sunken, good color 1 

Sunken and congested 1 

4 

Tuning-Fork Test. 

Uncertain 1 

Both aerial and bone conduction 1 

2 
Age: 

" In infancy " 1 

Whooping-cough, intermittent fever at two years and nine 
months 1 

2 

Table XVII. — Cholera Infantum Cause of Deafness, Condition of 'Membrana Tim- 
pani (1 case, 2 ears). 
Sunken, no light spot , 11 

Tuning-Fork Test. 

Bone conduction only 2 

Age one year. 

Table XVIII. — Gastric Fever Cause of Deafness, Condition of Membrana Tympani 

(1 case, 2 ears). 

Sunken, opaque, small light spot 1 

Sunken, good color, small light spot 1 

2 

Tuning-Fork Test. 

Bone conduction only, and that feeble 2 

Diseases at two years and eight months. 

Table XIX. — Intermittent Fever Cause of Deafness, Condition of Membrana Tym- 
pani (1 case, 2 ears). 
Small light spot 2 

Tuning- Fork Test* 
Bone conduction only 2 

Intermittent fever and spasms at two years. 



694 CAUSES OF DEAF-MUTEISM. 

Table XX. — Mumps Cause of Deafness, Condition, of Membrama Tympani (2 

cases, 4 ears). 

Eight opaque, small light spot ; left fair light spot, good color, 

sunken 2 

Eight and left cicatricial 2 

4 
Tuning-Fork Test, Unreliable. 
Age: 

A few months old 1 

Six years 1 



Table XXI. — Fever Cause of Deafness, Condition of Membrana Tympani (3 cases, 

6 ears). 

Sunken, two light spots 2 

Sunken, small light spot 2 

Opaque, small " " 1 

Cicatricial 1 



Tuning-Fork Test. 

Both aerial and bone conduction , „ . . 2 

Bone conduction only 4 

6 

Nine months , 1 

Five years 2 



Table XXII. — Cases in which Words or Letters could be Heard through a Speaking- 
tube placed in the Ear ; l Coridition of Membrana Tympani (16 cases, 32 ears). 

Opaque 6 

Sunken 15 

Good color , 4 

Good light spots . . 8 

Small " " 6 

No " " 6 

Two light spots 1 

Cicatricial 5 

Calcareous 1 

Vascular 1 

Perforated 2 

Not well seen 3 

1 In this table the various appearances of the membrana tympani are noted without 
regard to the number of ears. 



CAUSES OF DEAF-MUTEISM. 695 

Tuning-Fork Test. 

Both aerial and bone conduction , 4 

Bone only 2 

Bone both sides, aerial on one side 3 

Bone and aerial on one side, neither on the other 1 

Neither bone nor aerial on either side , 2 

Unreliable 4 

16 

Disease Causing Deafness. 

Born deaf 5 

Measles 4 

Cerebro-spinal meningitis 3 

Brain fever 1 

Convulsions 1 

Scarlet fever 1 

Unknown 1 

16 

To this last table, the words of Mr. Greenberger should be 
added : 

" The speaking-tube is used in these cases to assist the schol- 
ars to speak better after they have learned to pronounce them 
from the lips. There is not a pupil in the school who could be 
taught to speak a word from hearing it through the tube alone, 
but they will recognize words with which they have become fa- 
miliar through lip-reading." 

A study of these tables, especially with reference to the con- 
duction of sounds to the ears or auditory centres through bone, 
indicates to me that a large percentage of these deaf-mutes lost 
their hearing from disease of the middle ear, and that the acous- 
tic nerve was still capable of appreciating sound. It will be 
observed that in the column of the table in which the answer 
as to the perception of the sound of the tuning-fork through 
bone is given, it is stated in many instances that the subject of 
examination states tliat he or she "feels" it. I have endeav- 
ored to make the tables a mirror of what actually occurred in 
the examinations. It may be stated that to feel the vibrations 
of the tuning-fork is not to hear them, but I am inclined to think 
that in most instances, if not all, this perception is actually a 
perception of sound. A little thought as to what sound is will. 
I think, substantiate this view. We found, as will be seen, a 
small contingent who did not respond in any way to the vibra- 
tions of the fork. In this small contingent the functions or* 



696 CAUSES OF DEAF-MUTEISM. 

the nerve were probably destroyed. It is natural to suppose 
that about the same proportion of infants and very young chil- 
dren would suffer a lesion of the middle rather than the internal 
ear, in case the organ is attacked by disease, as would be the 
case in adults, and this seems to be indicated by these tables. 

The deaf-mutes from whom these tables are made up, are, 
so to speak, selected cases, for all or nearly all of them have 
good intellects and are capable of being taught. There do not 
appear among them, therefore, any cases in which there is a 
lack of ordinary cerebral development. In classifying unse- 
lected deaf-mutes, or those taken from the whole number to be 
found in a district or county, the number of those deaf from 
disease of the central apparatus would, of course, be increased. 

It is interesting to notice that a larger number of the cases 
are attributed to cerebro- spinal meningitis than to any one 
cause. There were 27 cases of this kind to 16 of scarlet fever. 
''Brain fever*' or meningitis plays an important part in the 
etiology, for there were 17 cases among the total number of 147. 
I cannot but hope that the careful instruction of the public and 
the profession, as to the necessity for the treatment of suppura- 
tion of the ear, has borne fruit, in the prevention of many cases 
of destruction of the ears by the means used to stop the inflam- 
mation. In the examinations made by Dr. Beard and myself 
some eighteen years ago, there was a larger percentage of cases 
caused by scarlet fever and producing suppuration in the middle 
ear. We seem as yet without means of successfully treating an 
inflammation of the ear, when it occurs in the course of cerebro- 
spinal meningitis. If there be an inflammation of the mem- 
branous labyrinth, which is mistaken for this disease, it is as 
yet not at all recognized by the profession at large. 

The observations of Mr. Lawson Tai' 1 upon the congenital deafness of white 
cats have an interesting bearing npon the situation of the lesion in deaf-mutes. 
Mr. Tait says of a cat that lived in his house for eleven years, that he was deaf 
to impressions conveyed through the air, "but his intelligence could be reached 
by impressions conveyed through solid media." "When he was wanted, he would 
respond to a peculiar stamp on the floor. After this interesting statement, Mr. 
Tait passes, as it seems to me, out of the region of facts, to state that ' ' human 
deaf-mutes are those in whom deafness is cochlear as well as tympanic." From 
this premise he concludes that cats are not mutes because their deafness has a 
tympanic origin. But human mutes emit sounds of various kinds as well as 
animals who ave deaf. The origin of the muteness is to be found in the 
non-ability of hearing, and not in the situation of the lesion that causes the 
deafness. The post-mortem investigation of Mr. Tait's cat was most interest- 
ing. It was made by Drs. Cumberbatch and Dr. Gibbs. All the structures in the 



Xature, December 13, 1883, and January 10, 1884. 



CONGENITAL DEAFNESS OF CATS. 



697 



ear were found to be normal, save the tympanic membranes, " in which there were 
triangular gaps extending from the roof to just below the centre, the bases of 
the gaps being directed upward, and the anterior sides being formed by the 
handle of the mallei. The gaps appeared to be congenital and were quite sym- 
metrical." All the other parts of the ear were normal. The auditory nerves were 
of normal size and structure. 



MECHANICAL APPARATUS FOE, ASSISTING THE HEAPING. 

The hearing-trumpet remains as yet the best means, in the 
greater number of cases, of increasing the hearing power. The 
aucliphone invented by Mr. Rhodes, of Chicago, is of equal value 
in some cases, and is preferred by those who are able to use it. It 
is more easily held, and less conspicuous. I think no one is 
benefited by a hearing-trumpet or audiphone, unless the loss of 




Fig. 136.— Hearing-Trumpets. 



Fig. 137.— Auricles. 



hearing be due to disease of the middle ear, or to a want of 
power over the tympanic muscles occurring in old age, which 
I would style presbykousis. As yet, hearing-trumpets and the 
audiphones must be carefully tested by the patient himself be- 
fore it can be certainly known that he will be materially assisted 
by them. I have lately seen a case of watering of the eyes, that 
seemed to be caused by the use of the audiphone. The patient 
stated that great lachrymation occurred whenever she used the 
instrument for a long period, which lasted for seme time. If 
she did not use it for a few hours, the watering would lessen or 
disappear. Many patients speak of the fatigue o\' listening with 
a hearing-trumpet, while others never seem to experience any 
such sensation. 



698 



AUDIPHONE. 



The accompanying figures give a fair idea of the general 
form of the most useful hearing-trumpets, and of the audiphone 
and its use, as well as of the so-called auricles. The latter are 
unsightly but of some value. 





Fig. 138. — The Audiphone in its nat- 
ural position ; used as a fan. 



Fig. 139. — The Audiphone in tension ; 
the proper position for hearing. 



Politzer has invented a small instrument in the form of a 
hunting-horn, whose narrower inner end is placed in the meatus, 
while its outer and broader part lies on the auricle, so that its 
opening is directed straight back against the concha. Politzer 




Fig. 140. — Method of Using the Audiphone. 



states that the principle of his instrument is based on the physio- 
logical fact, that sound acting on the ear, is heard more loudly 
when the surface of the tragus is enlarged posteriorly by plac- 
ing a small solid plate upon it. I have not yet seen any marked 



INSTRUMENT FOR IMPROVING HEARING. 699 

benefit to the hearing from Politzer's instrument, but I have had 
but few opportunities of trying it. 

I am not without hope, as I have already said in this work, 
that we shall yet make an apparatus which will improve the 
hearing of such persons as are deaf from disease of the middle 
ear, and who hear well in a noise, as well as for those who are 
presbykousic. Those deaf from disease of the nerve, must re- 
main without aid, just as those who suffer from disease of the 
optic nerve or retina cannot find lenses that will enable them to 
see. 



DESCRIPTION OF THE CHROMO-LITHOGRAPHS. 



Fig. 1. — Normal membrana tympani. 

It is impossible to exactly render the normal tint of this beautiful structure, 
but this lithograph seems to me to approximate this to a very satisfactory 
degree. 

Fig. 2. 1 — In this case, that of a man thirty- two years of age, a purulent in- 
flammation of the middle ear had existed for nearly two years. There was a 
perforation in front of the malleus, which finally healed under the application 
of nitrate of silver, forming the cicatrix shown in the drawing, and also a small 
circular opening through the "pars flaccida " — the space within the opening, 
and around the malleus-incus articulation being filled with small granulations. 
After the closure of the lower perforation, these were treated by application of 
saturated solution of arg. nit. on a cotton-tipped probe, with good result. The 
outer layer of the membrana tympani, above and behind the processus brevis, 
was much thickened and congested, and this condition (as shown in the draw- 
ing) continued after the closure of the inferior perforation. This plate is of 
value, as exhibiting a comparatively rare form and position of perforation of the 
membrana tympani, and one not readily amenable to treatment. 

Fig. 3 represents a small perf oration, the consequence of purulent otitis 
media, occurring in a boy twelve years of age, and of one year's duration. 
There were no granulations at the time when the drawing was made, and the 
perforation was in process of healing, as is shown by the congested blood-vessels 
extending from the periphery toward the perforation. This drawing exhibits 
the want of clearness of the outline of the malleus, as the result of thickening 
of the outer layer of the membrana tympani, and also the prominence of the 
processus brevis and of the posterior fold, in consequence of the concavity of 
the membrana tympani. Through the perforation is seen the congested mucous 
membrane of the middle ear. 

Fig. 4. — A case of purulent otitis media, in a boy twelve years of age. This 
drawing represents faithfully the granulations occurring on the membrana tym- 

1 The cases here described were treated by Drs. ,C. J. Blake and H. L. Shaw, of 
Boston. 



DESCRIPTION OF CIIROMO-LITIIOGRAPHS. 701 

pani, and also the thickening of the membrana tympani, subsequent to the per- 
foration, and during the continuance of the purulent inflammation. This case 
was convalescent at the time the drawing was made, under the application of 
astringents to the middle ear, and the granulations were rapidly diminishing 
under the application of arg. nit. In this drawing, also, is shown the peculiar 
arrangement of the blood-vessels passing from the superior wall of the meatus 
into the membrana tympani, to assist in forming the manubrial plexus, and 
which are congested in consequence of the diseased condition of the tympanum 
and membrana tympani. 

Fig. 5 represents a case of chronic catarrhal inflammation of the middle ear, 
accompanied by great concavity of the membrana tympani. The processus bre- 
vis is very prominent, and both anterior and posterior folds of the membrana 
tympani are consequently elongated. The handle of the malleus is much fore- 
shortened, and the lower end nearly in contact with the promontorium, as is 
shown by the lighter color of the membrana tympani at this point, the light rays 
being reflected directly from the white surface of the promontorium. The con- 
cavity of the membrana tympani is further evidenced by the character of the 
light reflection, which, instead of being a perfect cone, as represented in Fig. 1, 
is represented by two small points of light, one close to the end of the malleus, 
and one at the periphery ; the intermediate space representing a surface of such 
degree of concavity that the light thrown upon it from the mirror is focussed at 
a point within the meatus. 

Fig. 6 is a type of cases of chronic catarrhal inflammation of the middle ear, 
of long standing, in which the mucous coat of the membrana tympani has become 
uniformly thickened, with but a slight degree of concavity of the membrana 
tympani ; the latter condition in this case is principally evidenced by the prom- 
inence of the manubrium and processus brevis, and of the posterior fold. The 
same dull gray color is found, as a result of thickening of the mucous coat of 
the membrana tympani, followed by acute inflammation of the middle ear. 

This drawing exhibits also the appearance characteristic of, and the form 
peculiar to, large calcareous deposits. The light reflex is wanting, in conse- 
quence of the presence of the calcareous deposit at the point at which this ap- 
pearance is found in the normal membrana tympani. 

Fig. 7 represents a condition common to chronic catarrhal inflammation of 
the middle ear. In this case the malleus is in contact with the promontorium, 
and the continuance of the atmospheric pressure from without has carried the 
membrana tympani inward, rendering the malleus exceedingly prominent. The 
light color of the central portion of the membrana tympani is due to the reflec- 
tion of light from the inner wall of the tympanum, and not to thickening of the 
mucous coat. This condition is found where the trouble has been confined 
principally to the mucous membrane of the Eustachian tube and anterior portion 
of the tympanum, without the thickening of the inner coat of the membrana 
tympani, which is shown in Figs. 5 and 6, 

Fig. 8 exhibits the result of purulent inflammation of the middle ear of 
long standing, in a boy ten years of age. At the time of the drawing the dis- 



702 DESCRIPTION OF CHPwOMO-LITHOGEAPHS. 

charge had ceased, under treatment with dry cotton packing applied daily, 
and the mncous membrane was returning to a normal condition. There were 
two large perforations, divided by a narrow bridge of thickened membrana tym- 
pani. The short process of the malleus was very prominent, and the manubrium 
in contact with the promontory. The remainder of the membrana tympani was 
much thickened. The slight congestion about the short process, and along the 
manubrium, was due to the pressure of the cotton plug, as there was no evi- 
dence of a process of repair about the edges of the perforation. 



N° 1. 



N° 2. 





N° 3. 



N° 4. 





N° 5. 



N°6. 





N° 7. 



N°8. 





II. I' Ifl'ISl'V, M.D. All NAT. » 



DISE VSES 01 



INDEX OF AUTHORS. 



Achilini, 5 

Agnew, C. R., 104, 323, 452, 482, 484, 486, 

487, 492, 502, 509, 517, 529 
Agricola, Rudolphus, 21 
Albini, O. S., 86 
Albutt, 552 
Alcmseon, 4 
Allen, Peter, 36, 76 
Ambrose, D. R., 517, 645 
Andrews, J. A., 552 
Archigenes, 16 
Arcularius, Johannes, 19 
Aristotle, 4 

Arneman, J., 504, 506 
Arnold, F., 11, 203, 232, 251 
Asclepiades, 15 
Aurelianus, 17 
Ausspitz, 118 



Baldwin, 625 

Banze, Marcus, 22 

Bartlett, 432 

Beard, George M., 405, 458, 659, 684 

Beck, Karl Joseph, 25, 28, 102 

Benedetti, Alexander, 19 

Berengario, 5 

Berger, 505 

Bernard, Claude, 266 

Bertho'ld, 456, 588 

Billington, C. E., 302 

Billroth, Theodor, 103, 470, 540 

Bing, 58 

Bishop, Edward, 400 

Blake, Clarence J., 57, 64, 111, 142, 145, 

180, 253, 254, 432, 476, 479, 483, 632, 

666 
Blau, 302, 303 
Bochdalek, 9, 215 
Boerhaave, 88 
Boke, 474 

Bonnafont, 11, 37, 403, 420, 481, 563 
Bottcher, 13, 5S8 
Bowman, W. , 584 



Boyer, 418 

Bozzini, 66 

Brandeis, 115 

Brendel, 9 

Bremer, V., 482 

Breschet, 11, 577 

Briddon, C. K., 324 

Brodie, Sir Benjamin, 193 

Broca, 541 

Brown, F. T = , 522 

Brugsh, G., 4 

Brunner, 233, 625, 634 

Buchanan, Thomas, 11, 28, 175, 418 

Buck, A. H., 18, 36, 46, 106, 135, 137, 154, 
165, 188, 233, 254, 257, 271, 300, 301, 
322, 357, 388, 417, 432, 451, 470, 492, 
493, 502, 508, 509, 538, 585, 634 

Biickner, 123 

Bull, Charles S., 146, 345 

Bull, George J., 685 

Burkner, 211 

Burnett, C. H., 36, 88, 106, 254, 336, 356, 
388, 432, 510, 562 

Burnett, S. M., 148, 603 

Busson, Julian, 26, 414 

Butcher, William, 419 

Buttles, M. S., 403 



Cameron, 535 

Camper, 10 

Capivacci, 19 

Cardan, Jerome, 21 

Carpenter, 193 

Carpenter, W. M., 324 

Cassebohm, J. H., 9 

Cassells, J. Patterson, 37, 388, 394 

Casserius, Julias, 7 

Catlin, 394 

Celsus, 15, 469 

Cerlata, rotor do la, 18 

Chassaignao, 540 

Choyan, 541 

Cheselden, Thomas, 413 

Chimani, 105, 114, -ITS 

Clarke, Edward 11., 35, L92, 477 



704 



INDEX OF AUTHORS. 



Clarke, Lockart, 205, 207 

Claudius, 18 

Cleland, Archibald, 25, 70 

Cloquet, 11 

Clymer, Meredith, 640 

Cock, Thomas F., 332 

Cocks, David C, 490 

Cogsin, David, 58, 

Cohen, 68 

Coles, 369 

Columbo, 6 

Conta, von, 51 

Cooper, Sir Astlev, 27, 37, 252, 413, 414, 

415, 420, 433, 446 
Cornwall, 388 
Corti, Marchese, 13, 580 
Cos, 3 
Cotugno, 9 
Cousins, 126 
Cox, 546 

Crampton, Sir Philip, 530 
Crosby, A. B., 503, 509, 517 
Cruveilhier, 654 
Cumberbatch, 657, 696 
Curtis, John Henry, 28, 38, 418 
Cutter, Ephraim, 392 
Cuvier, 6 
Czermak, 67, 368 



Dalby, W B., 35, 634 

Dalton, 265 

Darling, William, 194 

Darwin, 88 

Degravers, 414 

Deiters, 13 

Delafield, F., 154 

Deleau, 28, 418 

Delechorriere, 299 

De Vigo, 20 

Dienert, 414 

Dioscorides, 17 

Di Rossi, 35, 64, 684 

Dominic, Cotugno, 9 

Duchenne, 86 

Du Verney, 8, 22, 188, 445 

E 

Ebers, George, 3 

Eisell, 233 

Eli, 414 

Elsber?, Louis, 186, 383 

Ely, E^T., 160, 310, 315, 319, 367, 394, 452, 

455, 480, 502, 522, 544, 614, 615 
Ely, W. S., 130 
Emerson, J. B., 54, 154, 162, 359, 497, 600, 

685 
Empedocles, 4 
Eno, Henry C, 471 
Erasistratus, 4 
Erb, 658 



Erhard, Julius, 34 

Esser, 87 

Eve, F., 105 

Eustachius, Bartolommeus, 6, 250 

Evsell, 509 



Fabricius of Aquapendente, 7 

Fabricius of Hilden, 203 

Fallopius, Gabriel, 6, 19 

Farnham, H. P., 398 

Field, Georse P.. 36, 347, 486 

Fielitz, 355,^505, 508 

Fischer, Alexander, 10 

Fisher, Lewis, 311 

Fisher, 497 

Flint, Austin, Jr., 265 

Follin, 503 

Forest, Peter, 20 

Fox, Cornelius B., 205, 207 

Francis, George E., 528 

Frank, Martel, 31, 62, 104, 387, 417 



Gadesden, 18 

Galen, 4, 5, 15, 16, 569 

Garrod, 120 

Gerlach, 12, 222 

Gevnes, 5 

Gibbs, 696 

Goethe, 251 

Goodwillie, 68 

Gottstein, 303 

Graefe, von. A, 621 

Graham, 112 

Green, John, 262, 433 

Green, J. Orne, 18, 142, 149, 188, 206, 268, 

372, 412, 428, 494, 528 
Greenberger, 685, 695 
Griesinger, 653 
Gross, S. D., 165, 187 
Gruber, Ignaz, 60 
Gruber, Josef, 9, 34, 75, 205, 215, 259, 

340, 372, 374, 389, 424, 426, 474, 529, 

539, 563, 603, 607, 612 
Gruening, E., 121, 481, 482, 503, 510 
Gudden, 110 
Guidi, 18 

Gull, Sir William, 542 
Guve, 403 
Guyot, 25, 70 



H 



Hackley, Charles E., 259, 275, 297, 387, 

400, 444, 478, 531 
Haeckel, 88 
Haller, 10 
Hallier, 145 
Hammond, W. A., 323, 619, 631 



INDEX OF AUTHOKS. 



705 



Harlan, G. C, 634 

Harless, 87 

Hartmann, J., 21, 37, 428, 463 

Hassenstein, 145 

Hecksher. 201 

Heller, 627 

Helmholtz, H., 218, 232, 254, 426, 588, 602 

Helmont, von, 22 

Hendriksz, 419 

Henle, J., 573, 576 

Hensen, 87, 253, 254, 255, 587 

Heraclides, 15 

Herodotus, 14 

Herophilus, 4 

Hessler, 540, 548 

Hewitt, Prescott, 547 

Himly, Karl, 415, 418 

Hinton, James, 13, 32, 36, 293, 346, 372, 

412, 418, 430, 443, 444, 449, 451, 457, 

503, 634, 653 
Hippocrates, 4, 14, 15, 188 
His, 368 

Hoffman (of Westphalia), 33, 62 
Hoffmann, Friederich, 24 
Hogyes, 588 
Holt, B. E., 76, 356 

Home, Sir Everard, 10, 27, 175, 415, 603 
Horst, Gisbert, 20 
Houghton, 380 
Hubbard, Robert, 513, 609 
Hun, E. R., 107 
Hunold, 418 
Hunt, David, 102 
Huschke, 11, 579 
Hutchinson, Jonathan, 549, 608 
Hyrtl, Joseph, 9, 13, 84, 85, 92, 215, 425, 

573, 585 



Ingrassia, 6 

Itard, 28, 418, 433, 445 



Jackson, Hughlings, 549, 654, 656 

Jacobi, A., 302, 621 

Jacobson, 11 

Jacoby (of Berlin), 503, 508, 509 

Jaeger, Edward, 62 

Jasser, 505 

Johannes, 11 

Jones, Handfield, 198 

Jones, H. Macnaughton, 36 

Jones, T. Wharton, 11, 216, 572, 575 

Joux, Amedee, 97 



K 

Kessel, Adolph, 470 

Kessel, J., 175, 216, 220, 222, 234, 238, 254 

Keyes, 614 

45 



Kinne, 187 

Kipp, C. J., 105, 115, 432, 510, 551 

Kirchner, 625 

Knapp, H., 35, 114, 149, 187, 388, 510, 603, 

628, 634, 641, 660 
Koiter, Volcher, 7 
Kolb, 494 
Kolliker, 13, 580 
Kolpin, 505 
Koeppe, 203 
Koppe, 244, 500 
Kramer, W., 28, 60, 149, 355, 362, 371, 400, 

403, 420, 591, 684 
Krause, 233 
Kuchenmeister, 141 
Kupper, 88, 203, 303 



Lallemand, 543 

Langenbeck, 190 

Lavater, 97 

Lebert, 542, 548 

Lewis, W. B., 146 

Liel, Weber, 35, 196, 382, 399, 412, 413, 

424, 426, 435, 482, 506, 548, 625 
Lincke, 3, 4, 37, 577 
Liston, 407 
Little, J. L., 633 
Loomis, A. L., 324, 327 
Loring, E. G., 64, 107, 270, 314, 387, 489, 

496, 534, 605 
Lowenburg, 139, 149, 192, 368, 452 
Luc*, Augustus, 12, 13, 57, 255, 353, 429, 

463, 628 
Luschka, 627 
Lusitanus, 21 
Lussana, 588 



M 



Mach, 87, 253, 254 

Maclagan, 204 

Magnus, 12, 262, 365, 433, 434 

Marcellus, 17 

Marin us, 4 

Mathewson, A., 34, 297, 387, 432, 458, 482, 

485, 490 
Maunoir, 417 
Mayer, Ludwig, 141, 176, 195, 201, 248, 

250, 252, 344, 503, 508, 509 
McKay, 535 
McKeown, 432 
Meckel, 10, 11 
Meniere, 13, 274, 655 
Merian, Burkhardt, 463, 494 
Merkel, 251 
Merrell, 314 
Metcalfe, John T., 311 
Meyer (of Hamburg), 111 
Meyer, Wilhelm, 367, 369 
Michael, 463 
Miohaelia, 417 



706 



INDEX OF AUTHOES. 



Millinger, 457 

Miot, 37 

Moldenhauer, 188 

Monro, Alexander, 10 

Moos, S., 13, 34, 35, 220, 363, 372, 443, 481 , 

482, 494, 587, 603, 612, 627, 628, 634, 

659 
Morgagni, 8, 10, 543 
Morgan, Lewis H, 394 
Miiller, Johannes, 11, 352, 474 
Munk, 588 
Murray, Adolph, 504 
Mussey, 105 



Newbourg, 60 

Newton, Homer G., 34, 539 

Niemeyer, 657 

North, Alfred, 488 

Noyes, H. D., 328, 371, 404,, 423, 432, 640 



Ormerod, 656, 65? 



Pacini, 141 
Pagenstecher, 508 
Paget, Sir James, 511 
Pappenheim, 232 

Pardee, C.'l., 387, 388, 396, 459, 489, 512 

Pare, Ambrose, 20, 460 

Patruban, 9, 214 

Paul of ^Egina, 17, 188 

Paullini, 23 

Pechlin, 202 

Peters, George A., 385, 533, 548 

Petit, Antoine, 26 

Petit, J. L., 24, 504 

Petrequin, J. E., 174 

Pierce, 173 

Piffard, H. G., 387 

Pilcher, George, 30, 198 

Pinkney, Howard, 435 

Pissot, 299 

Pliny, 4, 17, 469 

"piyj + oppTj A 

Politzer, Adam, 9, 13, 33, 34, 37, 45, 55, 
56, 57, 74, 105, 138, 165, 187, 202, 212, 
215, 217, 219, 233, 235, 254, 255, 258, 
304, 307, 341, 353, 361, 388, 412, 413, 
429, 434, 449, 454, 463, 478, 588, 698 

Pollak, 212 

Pomeroy, O. D., 37, 106, 114, 165, 298, 345, 
387, 391, 412, 476, 529 

Pooley, T. R., 115 

Portal 414 

Post, Alfred C, 494, 496, 503, 539 



Prescott, Royal, 310 
Pritchard, U., 453, 657 
Prout, J. S., 48, 403, 429, 458 
Prussak, 220 
Pythagoras, 4 



Quain, 205 



a 



R 



Ramsdell, E. B., 565 

Ranke, 587 

Rankin, F. H., 155, 398, 451 

Ranney, A. L., 538, 586 

Rau, 30, 356, 420 

Reid, James, 407 

Reiner, 37 

Reynolds, Russel, 657 

Rhazes, 18 

Riber, 417 

Rider, 452 

Richeraud, 433 

Ringer, S., 138 

Rinne, 88 

Riolanus, 413, 504 

Rivinus, 8 

Robertson, Charles A., 474, 479 

Robinson, Beverley, 369, 388 

Rockwell, A. D., 405,659 

Rohland, 286 

Rollfink, 504 

Rudinger, 34, 232, 245, 248, 252 

Rufus (of Ephesus), 4 

Rumbold, 388 

Rushmore, 272, 417 

Russell, 207 

Ruysch, 9 



Sabatier, 414 

Saissy, J. A., 28, 419, 433 

Sands, H. B., 324 

Sappey, 90, 92 

Sassonia, Hercules, 20 

Saunders, J. C, 10, 27, 37, 418 

Savage, 407 

Scarpa, Antonio, 10 

Schalle, 202 

Schaar, 57 

Schede, 509 

Scheibenzuber, 180 

Schlemm, 11 

Schmiedekam, 259 

Schmiedel, 9 

Schneider, 87 

Schultze, Max, 577 

Schwartze, Herman, 13, 27, 34, 56, 103, 
141, 188, 286, 298, 344, 372, 376, 413, 
414, 417, 418, 419, 421, 449, 456, 478, 
492, 502, 508, 509, 607, 654 



INDEX OF AUTHORS. 



707 



Seebeck, 253 

Seligman, Professor, 482 

Semeleder, 67, 368 

Sequard, Brown, 111 

Serapion, 18 

Sexton, Samuel, 89, 318, 510, 538, 660 

Shaw, Henry L., 268, 388 

Shrapnell, 11, 214, 263 

Simrock, 275 

Sims, J. Marion, 193 

Smith, Andrew H, 260, 433 

Smith, Gouverneur M., 299 

Smith, J. Lewis, 628 

Smith, Nathan R., 419 

Smith, Thomas, 106 

Soemmering, Thomas George, 11, 232 

Speir, B. D., 194 

Spencer, W. D., 311 

Steinbrugge, 13, 587 

Stenon, Mcholaus, 8 

Sterling, George A. , 544 

Steudener, F., 146 

Stevenson, 418 

Strawbridge, 510 

Sutton, 542 

Swieten, Van, 25 

Swift, Foster, 385, 548 



Tagliacottzi, Caspar, 21 

Tait, Lawson, 696 

Tangeman, 456 

Tansley, J. O., 75, 335 

Taylor, Fayette C. , 127 

Teole, 10 

Teulon, Giraud, 64 

Theobald, S., 347, 379, 432, 538 

Thudichum, 383 

Thurman, 110 

Tod, David, 10 

Todd, Robert B., 300, 584 

Tortual, 251 

Toynbee, Joseph, 11, 12, 13, 32, 33, 60, 74, 
110, 160, 252, 255, 264, 362, 372, 373, 
379, 420, 461, 483, 487, 531, 542, 634, 
684 

Triquet, 503 

Troltsch, Anton von, 12, 13, 18, 23, 32, 34, 
47, 60, 61, 96, 167, 179, 188, 202, 205, 
220, 221, 233, 234, 235, 248, 252, 264, 
274, 285, 328, 337, 340, 344, 355, 362, 
363, 372, 383, 400, 410, 420, 451, 461, 
485, 503, 504, 507, 529, 585, 591, 628, 
054, 666 

Tiirck, 368 

Turnbull, Lawrence, 35, 405 

Turner, 482 



Urbantschitsch, 405 



Valleroux, Hubert, 419 

Valsalva, Antoine Maria, 2, 8, 9, 24, 77, 

251, 504 
Van der Hoeven, 10 
Velpeau, 241 
Vesalius, Constant, 5 
Vieussens, Raymond, 8 
Virchow, Rudolph, 109, 471, 484 
Virsinier, 625 
Vogel, I., 141 
Voltolini, Rudolph, 13, 67, 184, 218, 233, 

368, 372, 424, 429, 529, 607, 627, 640, 

666 



W 



Wakely, T., 164 

Waldeyer, 582 

Wallis, John, 23 

Walther, 9 

Watham, Jonathan, 26 

Weber, C. O., 482 

Weber, E. H. (Leipsic), 11, 382 

Weber, Theodore, 382 

Webster, David, 172, 365, 497 

Weir, Robert F., 69, 154, 263, 274, 301, 

326, 404 
Welch, 154, 315 
Welcker, H., 482 
Wendt, 233, 302 
Wilde, Sir William, 2, 32, 38, 60, 66, 164, 

179, 204, 285, 338, 355, 362, 372, 379, 

414, 419, 443, 445, 474, 495, 503, 505, 

529, 591 
Williams, Joseph, 30 
Williams, A. D., 35, 131 
Willis, Thomas, 22, 354 
Wilson, F. M., 92, 187 
Winslow, 10 
Woakes, 206, 436, 562 
Wood, John, 179, 205 
Wollaston, 252, 602 
Wreden, Robert, 141, 145, 149, 184, 302, 

399, 423, 552 
Wright, C. E., 345 
Wyman, 483 



Yale, L. M., 623 
Yearsley, James, 30, 460 



Zaufal, 68 
Ziemssen, 80 
Zinn, 9 

Zoja, Giovanni, 241 
Zuckerkandl, E., 238 



INDEX OF SUBJECTS. 



A BSCESS of cerebrum, 453, 553-560 
xl of mastoid, 500 

of membrana tympani, 307 

of neck, 525 
Acoumeter, 45 

Actual cautery in non-suppurative inflam- 
mation, 424 
Adenoid vegetations in pharynx, 368 
Adhesions in the middle ear, 469 
Aerial conduction of tuning-fork, 54, 351, 

600 
Air. atmospheric, through catheter, 73, 395 
Air-bubbles in chronic catarrhal inflamma- 
tion, 342 

in perforation of membrana tympani, 
443 
Air, condensed, effects of, 261, 433 
Air, exhaustion of, from external auditory 

canal, 434 
Alcohol in suppuration of middle ear, 452, 

454, 478 
Albuminuria from chronic suppuration of 

middle ear, 444 
Alum powder in chronic suppuration of 

middle ear, 452 
Anchylosis of malleus and incus, 373 

of stapes, 373 
Aneurism, 653 
Angiomata, 105, 470 

case of, 121 
Angioma cavernosum, 471 
Anodynes, 130, 137, 288, 318, 565 
Anterior rhinoscopy, 68 
Anti-helix, 82 
Anti-tragus, 82 

muscle, 84 
Antrum mastoideum, 237 
Annulus tympanicus, 92, 220 
Aquseductus Fallopii, 6, 228, 549 
Artificial membrana tympani, 30, 460 
Aspergillus, 

cases of, 142, 149-152 

causes of, 143 

symptoms of, 144 

statistics of, 441 

treatment of, 148 

varieties of j 144 



Astringents, 

in acute suppuration of middle ear, 318 

in chronic inflammation of external 
canal, 134 

in chronic suppuration of middle ear, 
452 

in eczema, 118 
Atropia in diffuse inflammation of auditory 

canal, 131 
Attollens auriculam, 83 
Attrahens auriculam, 83 
Audiphone, 698 
Auditory canal, external, 

abscess of, case of, 167 

affections of, 122 

anatomy of, 90 

angles formed with membrana tym- 
pani, 92 

blood-vessels of, 96 

caries of bones of, 154 

casts of, 92 

chronic inflammation of, 134 

chronic suppuration of, 135 

circumscribed inflammation of, 136 

closure of, 18, 153 

condylomata of, 152 

eurvatures of, 91 

desquamative inflammation of, 135 

diffuse inflammation of, 123 
anodynes used in, 130 
case of, extending to tympanum, 333 
causes of, 125, 309 
incision in, 135 
objective symptoms of, 124 
popular remedies for, 130 
resume of treatment for, 131 
subjective symptoms of, 123 
treatment for, 127 

diphtheritic inflammation of, 153 

eczema of, 117 

examination of, 59-64 

foreign bodies in, 177 

furuncle of, 136 
causes of, 139 
treatment of, 137 

length of, 92 

lower animals, comparison of, 94 



710 



INDEX OF SUBJECTS. 



Auditory canal, external, 
narrowing of, 153 
nerves of, 96, 204 
polypi in, 124, 469 
physiology of, 96 
parasitic inflammation of, 141 
relations of, 95 
sarcoma of, 154 
statistics of affections of, 123 
suppuration of, 135 

case of, with inspissated cerumen, 
172 
syphilitic ulcers of, 152 
ulceration of, 134 
Auditory canal, internal, 4, 584 
Auditory nerve, 
atrophy of, 595 

cases of, 595-597 
concussion of, cases of, 651 
distribution of, 10, 581 
disease of, from cerebro-spinal menin- 
gitis, 626 

cases of, 629 
inflammation of, 595 
inflammation of, from meningitis, 630 

cases of, 630 
origin of, 582 
primary disease of, 591 

cases of, 595-597 
treatment of disease of, 598 
Aural clinics, 37 
Aural disease, extending from the pharynx, 

38, 65 
in constitutional disease, 308, 329 
first successful system of treating, 32 
Aural douche, l-i., 127, 317 
hallucinations, 344 
hemorrhage in Bright's disease, case 

of, 298 
syringe, 132 
Auricle, 

absence of, in mammalia living in 

water, 84 
anatomy of, 81 
angiomata of, 105 

case of, 121 
arrested development of, 100 
artificial, 697 
blood-vessels of, 86 
calcareous formations in, 120 
chondritis of, 113 

treatment of, 116 
deformity of, 101 

case of, 102 
detachment of, for removal of foreign 
body, 188 

cases of, 189, 191 
ear-rings causing tumor of, 104 
eczema of, 117 
epithelioma of, 116 
erysipelas of, 120 
fibro-cartilaginous tumors of, 103 
fistula of, 102 



Auricle, 

horny growths of, 106 
indicative of character, 97 
inflammation of, from wearing ear- 

rings, 83 
injuries of, 121 
intrinsic muscles of, 84 
malformation of, 98 
movements of, 86 
muscles of, 83 
mutilation of, supposed by ancients a 

cause of sterility, 22 
nerves of, 87 
operation for fibro-cartilaginous tumor 

of, 104 
perichondritis of, 113 

treatment of, 116 
physiology of, 87 
plastic operation on, 99 
prominence of, 98 

operation for, 99 
sarcoma of, 116 
sebaceous tumors of, 104 
superfluous, 101 
syphilis of, 106 
tumors of, 103 
vascular tumors of, 107 
Aurilave, 126 

Authorities consulted in historical sketch, 
39 



BINOCULAR otoscope, 64 
Bleeding from the ears in fracture of 
temporal bone, 271 
Blisters in acute suppuration of middle ear, 
318 
in disease of internal ear, 659 
in non-suppurative inflammations, 381 
Blood-letting, local, 127, 284, 300, 317, 

379, 494, 659 
Boiler-makers' deafness, 358, 644 
cases of, 647-650 
causes of, 645 

complicated with aural catarrh, 645 
pathology of, 647 
resume of knowledge of, 651 
treatment of, 658 
tuning-fork test in, 646, 650 
Bone-conduction in aural disease, 54, 351, 

600 
Bony growths, 480 
Boracic acid, 452 
Bougies, danger of use of, 403 
Bright's disease, 

case of cerebral hemorrhage in, 298 

(CALCAREOUS formation in auricle, 120 
J in membrana tympani, 364 
Canal, external auditory, 90 

diseases of, 122 
Canal, internal auditory, 4, 584 
growths in, 658 



INDEX OF SUBJECTS. 



711 



Carcinoma in the tympanum, 474 
Caries of mastoid, 500 

petrous bone, 535 

teeth, 563 

temporal bone, 24, 527 
treatment of, 537 

tympanic process, 154 
Catarrh of middle ear, acute, 276 

chronic, 341 

sub-acute, 291 
Cats, congenital deafness of, 695 
Cauterization of the pharynx, 381 

of polypi, 454 
Caustics, 454, 476 
Cerebral abscess, 453, 541 

cases of, tabulated, 554-560 
Cerebral symptoms, from inspissated ceru- 
men, 173 

case of, 167 
Cerebral tumor, 653 
Cerebro-spinal meningitis causing 

acute catarrh of middle ear, 283 

acute suppuration of middle ear, 308 

deaf-muteism, 304, 688 

disease of acoustic nerve, 626 

proliferous inflammation of middle 
ear, 376 
Cerumen, 

absence of, 163 

composition of, 174 

function of, 174 

increased formation of, in disease, 158 

inspissated, 156 
cases of, 166-173 

removal of, 165 
Chloroform, use of, 403 
Cholesteatoma, 474 
Chorda tympani nerve, 224, 236 

section of, 431 

injury of, 264 
Chromic acid, 477 
Chromo-lithographs, 700 
Cicatricial membrana tympani, 459, 469 
Circumscribed inflammation of external 

ear, 136 
Climate in aural disease, 437 
Cleansing the ears, method of, 132, 449 
Cochlea, 7, 10 

anatomy of, 573 

disease of, 592 
treatment of, 658 

physiology of, 586 

syphilis of, 608 
Cochlea nerve, 583 
Cochlitis, 608 

cases of, 613 
Cold in the head, neglect of, 295 
Concha, 82 
Concussion of labyrinth, 644 

cases of, 647-650 
Concave mirror, 63 
Condensed air, 261, 433 
Congenital deafness of white cats, 690 



Constitutional disease in aural disease, 308, 

329 
Conversation, test for hearing, 45 
Corti's organ, 580 
Corti's rods, 581 

Cotton as an artificial membrana tympani, 
460 
as a cleansing agent, 450 
plugging the ears with, in sea-bathing, 

125 
styptic, 286, 479 
Crista acustica, 577 
Cupping external auditory canal, 435 



D 



EAF-MUTEISM, 663 

cases of, 147 ; tabulated, 668-683 
cases in which words could be heard 

through speaking-tube, tabulated, 

694 
causes of, 665, 685 
caused by cerebro-spinal meningitis, 



cholera infantum, 693 
convulsions, 691 
fall, 690 
fever, 694 
gastric fever, 693 
hydrocephalus, 691 
intermittent fever, 693 
measles, 689 
mumps, 694 
pneumonia, 692 
scarlet fever, 687 
spinal meningitis, 692 
syphilis, 691 
varioloid, 692 
whooping cough, 693 
congenital, 689 
education of, 23 

examination of, with tuning-fork, 686 
forms of, 663 
treatment of, 667 
Deafness, absolute, 598 

not observed on account of occupa- 
tion, 340 
supposed incurable, 14, 18, 19 

work of the devil, 22 
to certain tones, 602 
Dentition, 280, 562 
Detachment of auricle, 18, 188 

cases of, 189-191 
Diagnosis, differential, of middle and in- 
ternal ear, 350 
tube, 371 
Diffuse inflammation of external auditory 

canal, .123 
Diphtheritic panotitis, 808 

inflammation of middle oar, 801 
Diplakousis, 603 
Disease of brain from aural disease, SO, 

198, 271. 310, 446, 483, 558 
Disease of middle oar and labyrinth, 599 



712 



INDEX OF SUBJECTS. 



Disproportion in hearing the tick of a 
watch and human voice, 49, 593 

Dohell's solution, 391 

Double hearing, 604 

Douche, aural, 127, 317 
nasal, 307, 382 

Dropsy of middle ear, 336 

Ductus cochlearis, 578 

EAR-ACHE, ancient treatment of, 14-17 
Ear-cough, 202 
Ear disease, neglect of, 289, 339 
Ear muffs, 126 
Ear protectors, 126 
Ear-rings, tumors from, 104 
Ear sand, 577 
Eczema of auricle, 117 

of auditory canal, 117 
statistics of, 441 
Electricity in diagnosis, 608 

in non-suppurative inflammation of 

middle ear, 405 
in disease of labyrinth, 659 
Eminentia stapedii, 234 
Emphysema from catherization, 408 
Endolymph, 577 

Entotic application of hearing trumpet, 58 
Epilepsy from aural disease, 176, 203, 657 

case of, 203 
Epithelioma of auricle, 116 

of middle ear, 474 
Erysipelas in aural disease, 524 

case of, 522 
Eustachian catheter, 69 

cause of coming into disrepute, 26 
danger of using, 405 
difliculty in introducing, 72, 371 
discovery of, 25 

in chronic non-suppurative inflamma- 
tion, 370 
introduction of astringents through, 

395 
method of using, 70 
Eustachian tube, 
anatomy of, 243 
blood-vessels of, 250 
bougies for dilating, 403 
broken catheter in, 202 
changes in, 367 
closure of, 24, 370 
diagnosis tube in examining of, 73 
escape of pus through, 308 
examination of, 
with bougies, 77 
catheters, 69 
Politzer's inflation, 74 
Valsalva's inflation, 77 
probes, 25 
rhinoscopy, 67 
first description of, 6 
first catheterization of, 25 
foreign bodies in, 178, 201 
case of, 202 



Eustachian tube, 

function of, 245, 255 

history of discovery, 6, 250 

inflation of tympanum through, 73 

in infants, 245 

injections of, 25, 39 

means of examination, 69 

measurements of, 242 

muscles of, 247 

naming of, 7 

nebulizer for, 401 

nerves of, 250 

shape of, 28 

smoking through, 413 

spraying through, 400 

treatment of, in aural disease, 395 

vapors in treating, 28, 397 
Examination of 

auditory canal, 59 

membrana tympani, 60 

patients, 44 

the ear by sunlight, 29, 63 
Exhaustion of air in auditorv canal, 434 
Exostosis, 162, 443, 480 

cases of, 486-490 

cause of, 483, 486, 490 

inflammatory, 483 

in skulls of Indians, 482 

treatment of, 484 
External auditory canal, 

anatomy of, 90 

diseases of, 122 
External ear, 79 
Eyelet, Politzer's, 423 

FACIAL paralysis, 197, 443, 549 
Facial nerve, 6, 229 
Fainting from syringing, 448 
Faucial catheter, 392 
Fenestra ovalis, 6, 8, 227 
Febrile symptoms in acute aural catarrh. 

282 
Fibromata, 470 
Fistula of auricle, 102 

mastoid, 501 
Fluids through Eustachian catheter, 398 
Fluid treatment of chronic suppuration of 

middle ear, 452 
Forceps, angular, 59 
Foramen of Rivinus, 216 
Foreign bodies in the ear, 
case of, 194 

causing cerebral symptoms, 197 
epilepsy, 197, 203 
facial paralysis, 197 
hemiplegia, 198 
inspissated cerumen, 162 
polypii, 190 
danger of indiscreet treatment, 183- 

191, 198 
death resulting from removal of, 198 
detachment of auricle for, 188 
cases of, 189, 191 



INDEX OF SUBJECTS. 



713 



Foreign bodies in the ear, 

diagnosis of, 201 

different kinds of, 178, 196 

hairs of canal on membrana tympani, 
200 

molten lead, 198 

reflex symptoms from, 203 s 

removal of, 15, 16, 19, 192, 196, 197 

statistics of, 177, 195 

supposed, 183 

Toynbee's artificial membrana tym- 
pani as, 200 
Forehead band, 63 
Fossa navicularis, 82 

sigmoidea, 237 

triangularis, 82 
Fracture of handle of malleus, 274 

temporal bone, 271 
French chalk in chronic suppuration, 451 
Fungus in solutions, 455 
Furuncle in auditory canal, 136 
Fused nitrate of silver, 457 

n ALVANISM in disease of labyrinth, 659 

VT Galvano-cautery, 478 

Gargles, 390 

Gargling, Von Troltsch's method of, 391 

General treatment in aural disease, 288 

Glands, ceruminious, 93 

Glycerine, 164 

Granulations, 477 

Graphium pencilloides, 144 

Gummata, 658 



HABENULA tectu, 580 
Haematoma, 107 
Hairs on membrana tympani, 200 
Hallucinations, 176, 344 
Harmonium test for hearing, 58 
Hearing, better in a noise, 22, 353, 361, 
593 
cases of, 354, 357, 360 
double, 603 
echo, 606 
tests of, 45 
trumpets, 697 

not lost by absence of membrana tym- 
pani, 24, 446 
disproportion of watch and voice test, 
49, 593 
Helices minor muscle, 84 

major muscle, 84 
Helicotrema, 575 
Helix, 4, 81 

Hemorrhage in auditory canal, 271 
in caries of temporal bone, 540 
in internal ear, 642 
Hemorrhagic inflammation of middle ear, 

295 
Hot water as a styptic, 479 
Hourteloupe's artificial leech, 28C 
Hydro-tympanum, 335 



Hygiene in aural disease, 374, 380, 

437 
Hyperostosis, 162, 480 



408, 



TLLUMINATION of the ear, 61, 63 

X Incisurse majoris auriculae Santorini, 

85, 91 
Incus, 230 
Inflation of middle ear, 

in diseases of internal ear, 594 

Politzer's method, 33, 74 
modifications of, 75, 76 

Valsalva's method, 77 

with catheter, 73 
Insanity, vascular tumors in, 107 
Insects in the ear, 179 
Inspissated cerumen, 

cases of, 160, 166-173 

causes of, 161 

diagnosis of, obscured, 158 

frequency of occurrence, 156 

mental depression from, 160, 176 

pain caused by, 159 

proper classification of, 157 

statistics of, 174 

structure of, 172 

suppuration with, 160 

symptoms of, 158 

symptom or result of disease, 156 

treatment of, 165 

tuning-fork test in, 159 
Inspissated mucus, 430 
Internal auditory canal, 584 
Internal ear, 568 

anatomy of, 569 

blood-vessels of, 585 

diagnosis of diseases of, by electricity, 
608 

diseases of, 590 

disease of, from spinal cord and me- 
dulla disease, typhoid fever and 
scarlet fever, 632 

disease of, from parotitis, 633 

hemorrhage into, 642 

inflammation of, 640 

injuries of, 643 

necrosis of, 530 

physiology of, 585 

symptoms of primary disease of, 593 

syphilis of, 608 

treatment of disease of, 659 
Intra-auricular pressure, 13 
Iodine vapor, 397 
Iodoform, 451, 478 
Iter chorda 4 anterius, 226 

posterius, 226 

JACOBSON'S nerve, 9 
Jugular vein, 447 

T7"ONIANTRON, 436 



714 



INDEX OF SUBJECTS. 



T ABYRINTH, 

_IJ acute inflammation of, 640 

anatomy of, 5(59 

anaemia of, 660 

concussion of, 644 

differential diagnosis of disease of, 601 

effects of quinine on, 619 

effusion into, 642 
case of, 643 

hemorrhage into, 642 

injuries of, 643 
cases of, 643 

leeches in disease of, 659 

membranous, 576 

pathology of disease of, 658 

periosteum of, 576 

sounds painful in disease of, 606 

symptoms of primary disease of, 607 

syphilis of, 611 
cases of, 609 

tonics in disease of, 6^0 

treatment of disease of, 658 
Lamina spiralis ossea, 575 
Lamps for aural work, 63 
Larvae in the ear, 179 
Lateral sinus, pus in, 536 
Laxator tympani muscle, 7 
Leeches in 

acute catarrh of middle ear, 284 

acute suppuration of middle ear, 317 

circumscribed inflammation of audi- 
tory canal, 137 

diffuse inflammation of auditory canal, 
129 

disease of labyrinth, 659 

mastoid periostitis, 494 
Levator auriculum, 83 
Levator veli palati, 249 
Ligamentum incudis superius, 232 

mallei anterius, 232 

mallei superius, 232 

obturatorium stapedis, 232 

spirale, 580 
Light spot, 

cause of existence, 217, 218 

measurements of, 217 

normal, 363 

in non-suppurative inflammation, 364, 
365 
Lobe, 83 

Local antiphlogistic treatment, 321 
Lung disease in ear troubles, 375 

MACULA acustica, 577 
Maculae cribrosae, 570 
Malformation of auricle, 97 
Malignant growths, 116, 474, 658 
Malingering, 58 
Malleus, 5, 230 

fracture of, 275 
Mastoid, 

abscess of, 491, 500, 516 

anatomy of, 236 



Mastoid, 

blood-vessels of, 241 
caries of, 500, 501 

cases of, 512, 513 

treatment, 501 
development of, 241 
enlargement of gland of, 496 
hyperostosis of, 492 
indication for trephining, 511 
in acute suppuration, 309 
lining of cells, 238 
oedema of, 496 
periostitis of, 491 

cases of, 497, 498, 518 

danger of, 493 

treatment of, 494 
sclerosis of, 492, 520 
trephining, history of, 503 
varieties of, 239 
Wilde's incision, 494 
Mechanical apparatus for assisting hearing, 

697 
Membrana basilaris, 579 
Membrana tympani, 
abscess of, 307 
artificial, 30, 200, 460 
blood-vessels of, 222 
bulging of, 281 

calcareous degeneration of, 363 
case of direct violence to, 270 
condition in acute catarrh, 280 
changes in mobility in non-suppura- 
tive inflammation, 365 
cyst of, 257 
diameters of, 213 
diseases of, 257 
examination of, 59 

of, on cadaver, 259 
first described, 4 
functions of, 252 
Hinton's operation on, 431 
inclination of, 212 
inflammation, case of, 333 
injuries of, 258, 263-267 

case of, 270 
light spot of, 364 
loss of, not a cause of total deafness, 

415 
lymphatic vessels, 224 
measurements of, 212 
minute anatomy of, 219 
nerves of, 222 
normal, 216 

objects for observation on, 216 
ossification of, 364 
paracentesis of, 27, 286, 429 
perforation of, 307, 442 
pigmentation of, 364 
position of, 212 
Prout's operation on, 430 
pulsation of, 281 

rupture of, 259, 260, 266, 271, 413 
cases of, 260 



INDEX OF SUBJECTS. 



715 



Membrana tympani, 

scarification of, 286 

secundarius, 227 

shape of, 213 

structure of, 11, 211 

sunken, 363 

thickness of, 219 

vascular tumor of, 300 
Membranous labyrinth, 576 
Meniere's disease, 343, 611 
Meningitis, 310, 314 

cases of, from inflammation of ear, 310, 
314 
Mental depression from inspissated ceru- 
men, case of, 160 
Microtia, 100 
Microzotes, 139 
Middle ear, acute catarrh of, 276 

bulging of membrana tympani in, 281 

causes of, 282 

febrile symptoms in, 282 

induced by quinine, 284 

hot douche in, 285 

leeches in, 285 

mastoid complications, 287 
case of, 513, 517 

neglect of, 278 

resulting from constitutional disease, 
283 

resulting from use of nasal douche, 283 

statistics of, 277 

symptoms of, 278 

treatment of, 284 
Middle ear, acute suppuration of, 305 

causes of, 307 

consequence of neglect of, 329 
cases of, 319, 331-334 

mastoid complication, 309 
case of, 520, 525 

prognosis of, 329 

phthisis pulmonalis complicating, 306 

pain in, 305 

symptoms of, 306 

treatment of, 316 

termination of, 309 
Middle ear. anatomy of, 213 

diseases of, 276 

physiology of, 252 
Middle ear, chronic catarrh of, 341 

causes of aural hallucinations, 344 

objective symptoms of, 350 

pathology of, 372 

subjective symptoms of, 342 

treatment of, 378 
Middle ear, chronic suppuration of, 

astringents in, 452, 459 

cases of, 464-467 

causes of, 439 

cleansing of tympanum in, 457 

cleansing with cotton in, 450 

confounded with inflammation of ex- 
ternal auditory canal, 440 

consequences of, 468 



Middle ear, chronic suppuration of, 

danger to health and life from, 468 

dry treatment of, 451 

electricity in, 458 

Eustachian tube in, 444 

granulations in, 454 

healing of membrana tympani in, 459 

impairment of hearing in, 446 

inflation in, 450, 454 

inspissated cerumen in, 442 

inspissated pus in, 457 

life insurance in, 468 

mastoid complications, 441 
cases of, 521 

method of cleansing, 449 

objections to use of syringe in, 448 

pain in, 442 

polypi in, 69 

perforations of membrana tympani in, 
439 

phthisis pulmonalis complicating, 460 

prognosis of, 463 

results of long-standing, 443 
of neglect, 445 

skin-grafting in, 455 

statistics of, 440 

supposed danger of stopping discharge 
of, 19, 445 

symptoms of, 441 

syringing in, 448 

treatment of, 447 

warm solutions in, 453 

warm water in, 448 
Middle ear, croupous inflammation of, 315 
Middle ear, diphtheritic inflammation of, 

301 
Middle ear, hemorrhagic inflammation of, 
295 

cases of, 296-298 
Middle ear, hypertrophic inflammation of, 

374 
Middle ear, neuralgia of, 561 
Middle ear, non-suppurative inflammation 
of, 337 - 

changes of membrana tympani in, 362 

differential diagnosis of, 350 

duration before advice is sought, 339 

paracentesis in cases of, 416 

pathology of, 373 

prognosis of, 409, 437 

supposed nervous deafness, 338 

symptoms of, 342, 349 

treatment of, 378 
Middle ear, proliferous inflammation of, 341 

causes of, 374 

constitutional remedies in, 379 

pathology of, 373 

prognosis of, 409 

symptoms of, 34!) 

treatment of, 379 
Middle ear, physiology of, 050 
Middle ear, sub-acute Inflammation of, 091 
cases of, 294 



716 



INDEX OF SUBJECTS. 



Middle ear, sub-acute inflammation of, 
pathology of, 293 

symptoms of, 291 

treatment of, 292 
Middle ear, serous inflammation of, 335 
Middle ear, statistics of occurrence of dis- 
ease of, 211 
Mineral acids in chronic suppurative in- 
flammation, 453 
Mixed cases, 350 
Modiolus, 7 
Mouth breathing, 394 
Mucous polypi, 470 
Mumps, cause of disease of ear, 633 
Muscida lucilia, 180 

sarcophaga, 180 
Muscles of auricle, 83 

of tympanum, 254 
Myringa, 7 
Myringitis, 257 
Myringodectomy, 424 
Myringomykosis, 142 
-Myringoplasty, 456 
Myxomata, 470 

TVT ARES in chronic catarrh of middle ear, 
1\ ' 370 

proliferous inflammation, 349 
Nasal catarrh, 

case of acute suppuration from, 333 
Nasal douche, 307, 382 

case of inflammation and pyaemia from, 
383 
Nasal speculum, 68 
Naso-pharyngeal inflammation, 375 
Nausea from syringing, 448 
Nebulizer, Eustachian, 401 
Nebulizer, naso-pharyngeal, 390 
Necrosis of 

auditory canal, 154 

labyrinth, 530 

temporal bone, 527, 537 
case of, 531 

case of, with membrana tympani in- 
tact, 529 
Nervousness, 592 
Neuralgia of ear, 561 

cases of, 564 
Neuroma of internal auditory canal, 658 
Nerve, auditory, inflammation of, 630 
Nerve deafness, 54, 590 

diagnosis of, 593 
Nitrate of silver, 452, 476 
Nitric acid, 476 
Noise, hearing better in, 353 

0BLIQUUS auriculae, 85 
Ophthalmoscope in aural disease, 551 
Ossicula auditus, 230 

adhesions of, 373, 469 
coverings of, 9 
dimensions of, 231 
discovery of, 5 



Ossicula auditus, functions of, 254 

ligaments of, 231 

loss of, case, 331 

mechanism of articulation, 232 

periosteum of, at birth, 221 
Osteo sarcoma of tympanum, 474 
Otalgia, 561 
Othgematomata, 107 

cases of, 109 

forms of, 107 

pathology of, 109 

treatment of, 113 
Otic ganglion, 235 
Otology, 

definition of, 2 

hindrance to the advance of, 38 

progress of, 1 
Otoconia, 577 
Otoliths, 577 

Otomyces purpuras, 144, 148 
Otorrhcea, 439, 443 
Otoscope, 

binocular, 64 

Blake's operating, 65 

interference, 58 

Von Troltsch's, 61 

PANOTITIS, 304, 307 
Paracentesis of membrana tympani, 
death following, 419 
first performed, 414 
for accumulations, 421 
history of, 413 
indications for, 416 
instruments for, 432 
statistics of, 421 
with galvano-cautery, 424 
Paracusis Willisiana, 22, 355 
Paralysis of seventh nerve, 549 

case of, from acute inflammation of 
ear, 321 
Parasitic inflammation of ear, 141 

cases of, 142, 149-152 
Paretic deafness, 435 
Parotitis, 633, 694 

cases of, 634 
Pathology, 

of labyrinthian diseases, 657 
of non-suppurative inflammation of 
ear, 372 
Pencillium, 148 
Pencillium glaucum, 144 
Perilymph, 569 
Periostitis, mastoid, 491 
Pharmaco-koniantron, 426 
Pharyngitis granulosa, 367 
Pharynx, 

astringents in treating the, 391 

examination of, 65 

gargles in treating the, 390 

Gruber's method of cleansing, 389 

injection of, 381 

in acute catarrh of middle ear, 287 



INDEX OF SUBJECTS. 



717 



Pharynx, 

in acute suppuration of middle ear, 318 

in chronic catarrh of middle ear, 448 

in chronic suppuration of middle ear, 
444 

in non-suppurative inflammation of 
middle ear, 367 

in proliferous inflammation, 349 

treatment of, 381 
Phlebitis in mastoid disease, 494 
Phlegmasia alba dolens, 494 
Phlegmonous inflammation of neck, 495 
Piano, test for hearing power, 58 
Plaster of Paris in suppurative inflamma- 
tion of middle ear, 451 
Polypi, 

cases of, 472, 473, 479 

cause of, 473 

classification of, 470 

in external auditory canal, 122 
tympanic cavity, 468 

nature of, 470 

on exostoses, 484 

origin of, 472 
of name, 469 

puncture of, 477 

removal of, with curette, 477 
with caustics, 450 
with forceps, 476 
with snare, 475 

resume of our knowledge of, 480 

treatment of, 475-478 
Pneumonia, 

case of aural disease from, 633 
Post-nasal syringe, 25, 381 
Poultices in 

acute catarrh of middle ear, 286 

mastoid periostitis, 494 
Pregnancy, cause of aural disease, 376 
Presbykousis, 598 
Probing, danger of, 156 
Proliferous inflammation of middle ear, 341 
Promontory, 228 

Pulsation in tympanic cavity, 443 
Pyaemia, 308, 453, 524, 544 

cases of, 383, 544 
Pyramid, 228 
Pyramis vestibuli, 571 

QUININE, effects of, 377, 619 
case of aural disease from, 169, 622 

RECESSUS cochlears, 571 
Record of patients, 44 
Reflex symptoms, 203 
Reissner's membrane, 580 
Register of hearing power, 48 
Resection of tympanic ring, 199 
Resorcin, 452 

Restiform bodies, section of, 111 
Retrahens auriculam, 83 
Rhinoscopy, 00, 369 



Rivinian foramen, 9, 214 

segment of membrana tympani, 214 

SACCULE, 578 
Salpingo-pharyngeus muscle, 249 
Santorini incisurae 
Sarcoma of auricle, 116 

internal auditory canal, 658 
Scala tympani, 575 
Scala vestibuli, 575 

Scarlet fever, cause of aural disease, 283, 
331, 632, 687 

cases of, 331, 633 
Sciatic nerve, effect on auricle of irritation 

of, 111 
Sea-bathing, cause of acute suppuration, 

308 
Semi-circular canals, 

anatomy of, 577 

bony, 572 

disease of, 654 
case of, 656 

first described, 5 
Sensory centre of auditory nerve, 588 
Sentences, test for hearing, 46 
Serous inflammation of middle ear, 335 
Shrepnell's membrane, 11, 214 
Siegle's otoscope, 336, 366 
Sinus subciformis, 571 
Skin grafting for loss of drum-head 455 
Small-pox, cause of aural disease, 692 
Sonofactors, 48 
Sound of one's voice in aural disease, 282 

determination of direction of, 589 
Speaking trumpets, 697 

tubes, 16, 697 
Speculum, 

anterior nasal, 68 

bivalvular, 60 

first used, 18 

for the ear, 60 

Siegle's, 336 

pharynx, 66 
Spheno-staphylinus muscle, 244, 247 
Stapedius muscle, 7, 233 
Stapes, 6, 231 

anchylosis of, 24, 373, 469 
Steam, use of, 396-398 
Stemphyllium, 145 
Sterility, ancient idea of cause of, 22 
Styptic cotton, 479 
Sulcus spiralis, 579 
Sulcus pro membrana tympani, 92 
Sulphate of zinc, 452 
Surf-bathing, protection of ours in, 283 
Supposed foreign body in ear, 198-200 
Suppuration of middle ear, acute, 305 

chronic, 439 
Syringe, 132, 448 

first used, 80 

method of using, 133 
Syringing 

for foreign bodies, 201 



718 



INDEX OF SUBJECTS. 



Syringing 

for furuncle, 137 

inflammation of external auditory 

canal, 134 
inspissated cerumen, 165 
naso-pharynx, 381 
parasitic inflammation, 148 
pharynx, Gruber's method, 389 
suppurative middle ear, acute, 317 
chronic, 449 
Syphilis of external ear, 152 
internal ear, 608 
middle ear, 376 

TEMPORAL bone, caries of, 24, 527 
Tensor palati muscle, paralysis of, 435 
Tensor tympani, 

action of, 12 

attachment of, 8, 234 

discovery of, 8 

function of, 254 

tenotomy of, 424 
Termination of diphtheritic inflammation of 

the middle ear, 303 
Tests of hearing power, 45 
Therapeutics, progress of, 13 
Tinnitus aurium, 

cause of, 347 

different sounds, 346 

effect on the mind, 344 
Tones, deafness for certain, 602 
Tongue specula, 66 

Tonsils in non-suppurative inflammation of 
the middle ear, 367 

removal of, 393 
Toynbee's disk, 461 
Tragi cus muscle, 84 
Tragus, 4, 82 
Transversus auriculae, 85 
Traumatism, cause of suppurative inflam- 
mation of the middle ear, 308 
Triangular spot of light, 217 
Trichothecium roseum, 144, 146 
Tubulus hirsutus, 176 
Tumors of auricle, 103 

of brain, 653 

of membrana tympani, 300 
Tuning-fork, 

discovery of use of, 19 

duration of vibrations, 55 

effect on membrana tympani, 13 

explanation of, 56 



Tuning-fork, 

history of its use, 52 

in disease of middle ear, 54, 350 

in disease of internal ear, 54, 600 

in disease of labyrinth, 593 

method of using, 52-57 

test for hearing power, 45, 51, 599 
Turkish bath, 380 
Tympanic syringe, Hartmann's, 459 
Tympanum, 

a series of anatomical parts, 443 

agents used through catheter, 400 

blood-vessels of, 234 

catheter for, 70, 398 

definition and description of, 225 

injecting with fluids, 431 

lining membrane of, 233 

measurements of, 226 

nerves of, 235 

objects for examination, 223 

openings in its walls, 227 

relations of, 229, 446 

roof of. 228 

syringing of, through Eustachian tube, 
457 

syringing, 450 

URINE, ancient instillation of, 23 
Utricle, 576 

YALSALVIAN experiment, 24, 364 
Vapors in non-suppurative inflamma- 
tion, 396 
Vertigo, 448 
Vestibule, 

anatomy of, 569 
physiology of, 586 
Vestibular nerve, 583 
Vomiting, effect of, 266 

WARM water instillation, 280, 448 
solutions, 453 
Watch as a test of hearing, 47 
Whooping cough, 693 

case of acute suppurative middle ear 
from, 332 
Wilde's incision, 495 
Worms in the ear, 15, 17, 23, 179 

ZONA denticulata, 13 
Zona pectinata, 13, 580 












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